FOREWORD

ii
 LIST OF CONTRIBUTORS
Ministry of Health
Dr. Anung Sugihantono, M. Kes
dr. Wiendra Waworuntu, M.Kes
dr. Sedya Dwisangka, M. Epid
dr. Endang Budi Hastuti
dr. Ann Natalia Umar
dr. Lanny Luhukay
dr. Irawati, M.Kes
dr. Triya Novita Dinihari .Sc
dr. Trijoko Yudopuspito, M.ScPH
Sugeng Wiyana, SKM, MPH
Sarikasih Harefa, SKM, M. Epid
Rudy E Hutagalung
Gestafiana, SKM, MKM
Irmawati, M. Kes
Viny Sutriani, S.Psi, MPH
Victoria Indrawati, SKM, MSc
University of Indonesia
Prof. drg. Indang Trihandini
Dr. Pandu Riono, MPH., Ph.D
Rico Kurniawan, SKM, MKM
Ryza Nur Jazid, SKM, MKM
Dion Zein, SKM
M. H. Thamrin University
Dr. Ajeng Tias Endarti, SKM, M.CommHealth
Fitriyani, SKM, M.Epid
Husnul Khatimah.,S.ST.,MKM
Ajeng Setianingsih, SKM, M.Kes
Laboratory Teams
dr. Yarne (BBLK Jakarta)
Rini Desiyantari, AMAK (BBLK Jakarta)
dr. Chairunnisa Tawadhu Rizal (BBLK Jakarta)
dr. Siti Kurnia Eka Rusmiarti, SpPK (BBLK
Jakarta)
Kambang Sariadji (NIHRD, MOH RI)
dr. Nelly Puspandari (NIHRD, MOH RI)
drh. Khariri (NIHRD, MOH RI)
Secretariat
dr. Sri Pandam Pulungsih, MSc
dr. Eddy Lamanepa, MPH
Sofie Yunita
Florens Sibarani
Nur Hasan Sorowi, SKM, MM
Ekhoris, SE
Atika Suryaningsih, S. Si
Damayanti, S.Sn
Merry Delwita, Amd
Siti Zarah Eka Putri, SKM
Provincial Field Coordinators
Ratnawati, SKM, MPH (Aceh)
Dian Febrianti (Riau Islands)
Lely Oktasistika (Bangka Belitung)
Arwan Nofri (North Sumatra)
dr. Asmarani Ma’mun, M. Kes (South Sumatra)
iii
Trinayanti (South Sumatra) World Health Organisation (WHO)
Otta Nur Kirana (Lampung) Fetty Wijayanti, M.Epid
Ratnasari, SKM (Banten) Dr. Yujwal Raj
dr. Anggoro Karlani Nurcahyono (DKI
Jakarta)
LINKAGES
Rosi Nurcahyani, S. Kep (West Java)
Siti Sulami, M.Epid
Sri Anerusi, SKM, M.Kes (Central Java)
Bayu Taruno, SKM
Arumsari wulandari, SKM (DI Yogyakarta)
Irma Siahaan, SKM
Agung Nugroho, SKM, MPH (East Java)
dr. Gde Agus Suryadinata (Bali)
UNAIDS
Rasmah, SKM, M. Kes (South Sulawesi)
Lely Wahyuniar, SKM
Oksye C. Umboh, S. Kep (North Sulawesi)
Rudi Anshari (West Kalimantan)
Non-Governmental Organizations
Reni Setiowati (East Kalimantan)
(NGOs)
Harry Abriandy (Central Kalimantan) OPSI
Joyce M. Tibuludji, SKM, M. Kes (East GWL-INA
Nusatenggara / NTT)
GWL-INA MUDA
Ernawati, Amd. Keb (West
Nusatenggara / NTB) PKNI

Syarifa Payapo, SKM (Maluku) YPI

Lenny Huaturuk (Papua) Rumah Cemara

iv
 TABLE OF CONTENTS
FOREWORD........................................................................................................................................................ ii
LIST OF CONTRIBUTORS .............................................................................................................................. iii
TABLE OF CONTENTS ......................................................................................................................................v
LIST OF TABLES ............................................................................................................................................... ix
LIST OF FIGURES ........................................................................................................................................... xiv
LIST OF ACRONYMS....................................................................................................................................... xv
EXECUTIVE SUMMARY ...............................................................................................................................xvii
Introduction ...................................................................................................................................................... 1
1.1 Background .......................................................................................................................................................... 1
1.2 Objectives .............................................................................................................................................................. 2
Method ................................................................................................................................................................ 3
2.1 Survey Design ...................................................................................................................................................... 3
2.2 Survey Location .................................................................................................................................................. 3
2.2.1 Consideration in Survey Location Selection ............................................................................ 3
2.3 Population ............................................................................................................................................................. 4
2.4 Samples .................................................................................................................................................................. 4
2.4.1 Sample Size .............................................................................................................................................. 5
2.5 Sample Collection Method.............................................................................................................................. 6
2.5.1 Time-Location Sampling (TLS) ........................................................................................................ 6
2.5.2 Respondent-Driven Sampling (RDS)........................................................................................... 7
2.5.3 Sampling Framework Construction............................................................................................. 8
2.6 Data Collection Instrument ..........................................................................................................................11
2.7 Biomarker and Laboratory Test ................................................................................................................13
2.8 Data Collection ..................................................................................................................................................14
2.9 Data Management ............................................................................................................................................15
2.9.1 Data Processing ....................................................................................................................................15
2.9.2 Data Quality ............................................................................................................................................17
2.9.3 Data Analysis.........................................................................................................................................17
2.10 Ethical Approval ............................................................................................................................................17
2.11 Report Layout .................................................................................................................................................18
Men who Have Sex with Men (MSM) ....................................................................................................... 19
3.1 Respondent Characteristics .........................................................................................................................20
3.2 Virtual Network ................................................................................................................................................26
3.3 Knowledge about HIV, Its Risk and Prevention ..................................................................................27
3.3.1 Knowledge about HIV .........................................................................................................................27
3.3.2 Risk Perception for HIV and Protective Behavior ...............................................................29
3.4 Condom and Sexual Behavior .....................................................................................................................30
3.4.1 Access to condom ...............................................................................................................................30
3.4.2 Sexual Behavior and Condom Use .............................................................................................33
3.5 Sexually-Transmitted Infection (STI) ......................................................................................................43
3.5.1 Symptom and Testing.........................................................................................................................43
3.5.2 STI Treatment ........................................................................................................................................44
3.6 HIV Test and Treatment ................................................................................................................................46
3.6.1 HIV Test and Testing Location........................................................................................................46
3.6.2 Reason for Getting or Not Getting HIV Test ...........................................................................47
3.6.3 Consent, Counseling and Receipt of HIV Test Result ........................................................49

v
 3.7 Tuberculosis (TB) ............................................................................................................................................51
3.8 Hepatitis...............................................................................................................................................................52
3.9 Coverage of Other Prevention Program .................................................................................................54
3.10 Positivity Rate .................................................................................................................................................56
Waria ................................................................................................................................................................. 60
4.1 Respondent Characteristics .........................................................................................................................61
4.2 Virtual Network ................................................................................................................................................66
4.3 Knowledge about HIV/AIDS, Its Risk, and Prevention .....................................................................68
4.3.1 Knowledge about HIV .........................................................................................................................68
4.3.2 Risk Perception and Knowledge about Prevention Method ..........................................70
4.4 Condom and Sexual Behavior .....................................................................................................................71
4.4.1 Access to Condom...............................................................................................................................71
4.4.2 Sexual Behavior and Condom Use .............................................................................................75
4.5 Sexually-Transmitted Infection (STI) ......................................................................................................84
4.4 HIV Program Coverage ..................................................................................................................................87
4.5 Tuberculosis, Hepatitis B and Hepatitis C..............................................................................................93
4.6 Coverage of Other Prevention Program .................................................................................................95
4.7 Positivity Rate ...................................................................................................................................................96
Female Sex Worker (FSW) ......................................................................................................................... 99
5.1 Socio-demographic Characteristics of FSW ....................................................................................... 101
5.1.1 Survey Venue ....................................................................................................................................... 102
5.1.2 Age............................................................................................................................................................ 103
5.1.3 Level of Education ............................................................................................................................ 104
5.1.3 Marital Status...................................................................................................................................... 104
5.1.4 Living Arrangement ......................................................................................................................... 105
5.1.5 Main Source of Income .................................................................................................................. 106
5.1.6 Identity Card Ownership and Health Insurance Coverage ........................................... 107
5.1.7 Monthly Income from Sex Work ................................................................................................ 108
5.1.8 Sex Transaction Venue in the Last Year ............................................................................... 109
5.1.9 Client’s Occupation in the Last Year ........................................................................................ 110
5.2 Virtual Network .......................................................................................................................................... 111
5.3 Knowledge about HIV/AIDS, Its Risk, and Prevention .......................................................... 113
5.3.1 Previous Exposure to HIV/AIDS Information and Source of Information ............ 113
5.3.2 Knowledge about HIV/AIDS......................................................................................................... 115
5.3.3 Risk Perception for HIV Infection and Protective Behavior........................................ 116
5.4 Sexual Behavior and Prevention ....................................................................................................... 116
5.4.1 Sexual Partner and Condom Use Consistency .................................................................. 117
5.4.2 Number of Clients in the Last Week ...................................................................................... 119
5.4.3 Reason for Not Using Condom in the Last Sex with Client ........................................ 120
5.4.4 Age at First Vaginal Sex ............................................................................................................... 121
5.4.5 Age at First Anal Sex ..................................................................................................................... 122
5.4.6 Age at First Time Selling Sex ..................................................................................................... 123
5.4.7 Age FSWs Expect to Stop Selling Sex ................................................................................... 124
5.4.8 Length of Time in Sex Work........................................................................................................ 124
5.5 Other Risk Behavior ................................................................................................................................. 125
5.5.1 Alcohol Consumption and Substance Abuse ...................................................................... 126
5.5.2 Coerced Sex ........................................................................................................................................ 127
5.6 Access to Condom ...................................................................................................................................... 128

vi
 5.6.1 Access to Condom ............................................................................................................................ 129
5.6.2 Source of Free Condom and Experience with Damaged or Torn Condom.......... 130
5.7 Sexually-Transmitted Infection (STI)............................................................................................. 131
5.7.1 STI Symptom, Testing and Treatment ..................................................................................... 132
5.7.2 Location of STI Testing and Treatment .................................................................................. 133
5.8 Human Immunodeficiency Virus (HIV) ......................................................................................... 135
5.8.1 HIV Test and Location of HIV Test............................................................................................. 135
5.8.2 Reason for Getting and Not Getting HIV Test ..................................................................... 136
5.8.3 Reason for Not Disclosing the HIV Test Result ................................................................ 137
5.8.4 HIV Test ................................................................................................................................................. 139
5.8.5 HIV Treatment .................................................................................................................................... 141
5.9 Tuberculosis (TB) ...................................................................................................................................... 142
5.10 Hepatitis....................................................................................................................................................... 144
5.10.1 Hepatitis B........................................................................................................................................... 144
5.10.2 Hepatitis C .......................................................................................................................................... 145
5. 11 Other Prevention Program ............................................................................................................... 145
5.11.1 Exposure to HIV Prevention Program ................................................................................... 145
5.11.2 Type of Information Received from Field Outreach Worker ...................................... 147
5.11.3 Barriers to HIV Service Access................................................................................................ 148
5.12 Positivity Rate ........................................................................................................................................... 149
5.12.1 Positivity Rate as an Aggregate ............................................................................................... 149
5.12.2 Positivity Rate Per District/Municipality ............................................................................. 151
Client ............................................................................................................................................................... 153
6.1 Socio-demographic Characteristics............................................................................................... 154
6.1.1 Survey Venue ....................................................................................................................................... 155
6.1.2 Age ............................................................................................................................................................ 156
6.1.3 Level of Education ............................................................................................................................ 157
6.1.4 Marital Status...................................................................................................................................... 158
6.1.5 Circumcision Status......................................................................................................................... 159
6.1.6 Health Insurance Coverage.......................................................................................................... 159
6.2 Knowledge about HIV/AIDS, Its Risk, and Prevention .......................................................... 160
6.2.1 Knowledge about HIV/AIDS.......................................................................................................... 160
6.2.2 Risk Perception for HIV Infection and Protective Behavior ........................................ 162
6.2.3 Reason Clients Feel At Risk of HIV Infection ..................................................................... 162
6.3 Sexual Behavior and Prevention ....................................................................................................... 164
6.3.1 Sex Partner and Condom Use..................................................................................................... 164
6.3.2 Average Number of Visit to FSW in the Last Six Months............................................. 167
6.3.3 Reason for Not Using Condom during Last Sex with FSW ......................................... 167
6.3.4 Age at First Vaginal Sex ............................................................................................................... 168
6.3.5 Age at First Anal Sex ..................................................................................................................... 169
6.3.6 Age at First Time Buying Sex ..................................................................................................... 171
6.4 Other Risk Behavior ................................................................................................................................. 172
6.4.1 Other Sexual Encounter ................................................................................................................ 173
6.4.2 Injecting Drug Use ........................................................................................................................... 174
6.6 Sexually-Transmitted Infection (STI)............................................................................................. 175
6.6.1 STI Testing and Treatment ............................................................................................................ 175
6.6.2 STI Treatment ..................................................................................................................................... 176
6.7 Human Immunodeficiency Virus (HIV) ......................................................................................... 176

vii
 6.7.1 HIV Status.............................................................................................................................................. 177
6.7.2 HIV Test.................................................................................................................................................. 177
6.7.3 HIV Treatment .................................................................................................................................... 178
6.8 Tuberculosis (TB) ...................................................................................................................................... 181
6.9 Hepatitis.......................................................................................................................................................... 181
6.9.1 Hepatitis B............................................................................................................................................. 182
6.9.2 Hepatitis C ............................................................................................................................................ 182
6.10 Positivity Rate ........................................................................................................................................... 183
6.10.1 Positivity Rate as an Aggregate ............................................................................................... 183
6.10.2 Positivity Rate Per District/Municipality ............................................................................. 184
PWID ............................................................................................................................................................... 186
7.1 Respondent Characteristics ................................................................................................................. 187
7.2 HIV Knowledge, Risk Perception and Protective Behavior................................................ 191
7.2.1. Knowledge about HIV ..................................................................................................................... 191
7.2.2 Risk Perception and Protective Behavior ............................................................................ 192
7.3 Injecting Drug Use ..................................................................................................................................... 194
7.3.1 Age at First Injection and Length of Drug Use ................................................................... 194
7.3.2 Type of Injectable Drugs Used ................................................................................................... 195
7.3.3 Injection Frequency and Needle Use Practices ................................................................ 196
7.3.4 Injection Venue and Source of Injection Needle .............................................................. 197
7.3.5 Correctional Facilities and Drugs ............................................................................................ 199
7.4 Sexual Behavior and Condom Use .................................................................................................... 200
7.4.1 Age at First Sexual Intercourse ................................................................................................ 200
7.4.2 Condom and Sexual Behavior.................................................................................................... 201
7.5 STI Symptom, Testing and Treatment............................................................................................ 204
7.5.1 STI Symptom and Testing .............................................................................................................. 204
7.5.2 STI Treatment ..................................................................................................................................... 205
7.6 HIV Test and Treatment ......................................................................................................................... 206
7.6.1 HIV Test and Test Location ........................................................................................................... 206
7.6.2 Reason for Getting and Not Getting HIV Test ..................................................................... 208
7.6.3 Consent, Counseling and Receipt of HIV Test Result ..................................................... 209
7.6.4 HIV Treatment and Viral Load Test among PWID ............................................................. 210
7.7 TUBERCULOSIS (TB) ................................................................................................................................ 212
7.8 Hepatitis.......................................................................................................................................................... 213
7.9 Coverage of Other Prevention Program ........................................................................................ 214
7.10 Positivity Rate of HIV, Syphilis and Hepatitis.......................................................................... 217
LIMITATION.................................................................................................................................................. 219
CONCLUSION AND RECOMMENDATION .............................................................................................. 220
9.1 Conclusion........................................................................................................................................................ 220
Men who have Sex with Men (MSM) .................................................................................................. 220
Waria.................................................................................................................................................................. 221
Female Sex Workers (FSWs) ................................................................................................................ 221
Clients ............................................................................................................................................................... 222
People who Inject Drugs (PWID) ......................................................................................................... 222
9.2 Recommendation .......................................................................................................................................... 223
REFERENCES................................................................................................................................................. 224

viii
 LIST OF TABLES
Table 2.1 Number of Selected Districts/Municipalities for Each Key Population .................................. 4
Table 2.2 Sample Size for Each Key Population .................................................................................................... 5
Table 2.3 Total Samples for Each Key Population................................................................................................ 5
Table 2.4 Total Samples for each Key Population at each 2018-2019 IBBS Survey Location ........... 9
Table 2.5 Topic of Questions in the Behavioral Questionnaire ....................................................................12
Table 2.6 Biological Specimen Collection and Testing in each Key Population .....................................13
Table 2.7 Biological Specimen Collection Sites for each Key Population .................................................13
Table 2.8 Stages of Activities in 2018-2019 IBBS ..............................................................................................14
Table 3.1 Data Collection Coverage among MSM ...............................................................................................19
Table 3.2 Age Group and Educational Level of MSM.........................................................................................20
Table 3.3 Marital Status and Living Arrangement of MSM .............................................................................22
Table 3.4 Employment, Health Insurance Coverage and Circumcision Status of MSM ......................23
Table 3.5 Gathering Places of MSM ..........................................................................................................................25
Table 3.6 MSM’s Internet Access, Information Search, Online Communication and Exposure
to Social Media ..................................................................................................................................................................26
Table 3.7 MSM’s Information and Knowledge about HIV ...............................................................................27
Table 3.8 Risk Perception and Protective Behavior of MSM..........................................................................29
Table 3.9 Ways to Obtain Condom, Places that Sell Condom and Places that Provide Free
Condom ................................................................................................................................................................................30
Table 3.10 Condom Brand, Condom Breakage and Use of Lubricant ........................................................32
Table 3.11 Age of MSM’s First Sexual Intercourse .............................................................................................33
Table 3.12 Sexual Behavior with Male Partner ...................................................................................................35
Table 3.13 Sexual Behavior and Condom Use with Commercial Male Partner......................................36
Table 3.14 Sexual Behavior and Condom Use with Waria..............................................................................37
Table 3.15 Sexual Behavior and Condom Use with Female Partner ..........................................................38
Table 3.16 Sexual Behavior and Condom Use with Commercial Female Partner.................................40
Table 3.17 Sex Party and Condom Use....................................................................................................................41
Table 3.18 Alcohol Consumption, Substance Abuse, Tattooing and Piercing among MSM ..............42
Table 3.19 STI Symptom and Testing among MSM ...........................................................................................43
Table 3.20 STI Treatment for MSM ..........................................................................................................................45
Table 3.21 HIV Test and Location of Last HIV Test ...........................................................................................46
Table 3.22 Reason for Getting or Not Getting HIV Test ...................................................................................48
Table 3.23 Consent, Counseling and Receipt of HIV Test Result.................................................................49
Table 3.24 HIV Treatment and Viral Load Test among MSM ........................................................................50

ix
Table 3.25 TB Symptoms, Testing and Treatment that MSM Experienced .............................................52
Table 3.26 Hepatitis Testing and Treatment among MSM .............................................................................53
Table 3.27 MSM’s Exposure to HIV Prevention Program................................................................................54
Table 3.28 Type of Information MSM Receive from Field Outreach Workers .......................................55
Table 3.29 Positivity Rate of HIV, STI and Hepatitis in MSM per District/Municipality ....................58
Table 4.1 Number of Samples Targeted, Collected, and Rate of Participation among Waria ..........60
Table 4.2 Age Group and Educational Level of Waria ......................................................................................61
Table 4.3 Marital Status and Living Arrangement of Waria...........................................................................63
Table 4.4 Employment, Health Insurance Coverage and Circumcision Status of Waria ....................64
Table 4.5 Internet Access, Information Search, and Online Communication of Waria .......................66
Table 4.6 Social Network Sites Frequented by Waria ......................................................................................67
Table 4.7 Waria’s Knowledge about HIV and Level of Comprehensive Knowledge ............................69
Table 4.8 HIV Risk Perception and Protective Behavior Adopted by Waria ...........................................70
Table 4.9 Ways Waria Obtained Condom in the Last Month .........................................................................72
Table 4.10 Places that Provide Free Condom for Waria ..................................................................................73
Table 4.11 Condom Brand, Condom Breakage and Use of Lubricant by Waria .....................................74
Table 4.12 Age of First Vaginal and and Anal Sex among Waria ..................................................................75
Table 4.13 Age Waria Respondents Started Buying and Selling Sex ..........................................................77
Table 4.14 Sexual Behavior of Waria with Steady Male Partner..................................................................78
Table 4.15 Sexual Behavior of Waria with Non-Steady Male Partner .......................................................79
Table 4.16 Sexual Behavior of Waria who Buy Sex from Men ......................................................................81
Table 4.17 Sexual Behavior of Waria who Sell Sex to Men .............................................................................82
Table 4.18 Other Risk Behavior of Waria ..............................................................................................................83
Table 4.19 STI Symptoms and Testing among Waria .......................................................................................85
Table 4.20 STI Testing Site, Consultation with a Health Provider and STI Treatment Facility
that Waria Visited ............................................................................................................................................................86
Table 4.21 HIV Testing among Waria ......................................................................................................................88
Table 4.22 Receipt of Test Result and Reason for Getting HIV Test among Waria ..............................89
Table 4.23 Reason for Not Getting HIV Test among Waria ............................................................................90
Table 4.24 Location of Last HIV Test and Reason for Not Disclosing HIV Test Result among
Waria ....................................................................................................................................................................................91
Table 4.25 HIV Treatment and Viral Load Test among Waria ......................................................................92
Table 4.26 Coverage of Program and Treatment for TB, Hepatitis B and C among Waria ...............93
Table 4.27 Waria’s Exposure to Intervention ......................................................................................................95
Table 4.28 Proportion of Diseases among Waria per District/Municipality ..........................................97
Table 5.1 Data Collection and Participation Rate among FSW .....................................................................99

x
Table 5.2 Biological Data Collection and Participation Rate among FSW ............................................. 101
Table 5.3 Survey Venues of FSW ............................................................................................................................ 102
Table 5.4 Age Group and Educational Level of FSW....................................................................................... 103
Table 5.5 Marital Status and Living Arrangement of FSW ........................................................................... 104
Table 5.6 Primary Source of Income among FSW ........................................................................................... 106
Table 5.7 Identity Card Ownership and Health Insurance Coverage of FSW ...................................... 108
Table 5.8 FSW Sex Transaction Venue in the Last Year ................................................................................ 109
Table 5.9 Occupation of FSW’s Client in the Last Year .................................................................................. 111
Table 5.10 Internet Access, Information Search, Online Communication and Exposure to
Social Media among FSW........................................................................................................................................... 112
Table 5.11 Source of HIV/AIDS Information among FSW ........................................................................... 114
Table 5.12 FSW’s Knowledge about HIV/AIDS, Its Risk and Prevention............................................... 115
Table 5.13 FSW’s Sexual Behavior and Consistent Condom Use with Steady and Non-Steady
Partner .............................................................................................................................................................................. 118
Table 5.14 Sexual Behavior, Consistency in Condom Use with Clients and Number of Clients
in the Last Week ............................................................................................................................................................ 120
Table 5.15 FSW’s Reason for Not Using Condom during Last Sex with Client .................................... 121
Table 5.16 Age of First Vaginal and Anal Sex among FSWs......................................................................... 122
Table 5.17 Age FSWs Started Selling Sex and Expect to Stop Selling Sex .............................................. 123
Table 5.18 Length of Time in Sex Work............................................................................................................... 125
Table 5.19 Alcohol and Drug Consumption among FSWs............................................................................ 126
Table 5.20 Coerced Sex among FSWs in the Indonesian 2018-2019 IBBS ........................................... 128
Table 5.21 Access to Condom and Brand of Condom used by FSWs ....................................................... 129
Table 5.22 Source of Free Condom and Experience with Torn Condom among FSWs ................... 130
Table 5.23 STI Symptom, Testing and Treatment among FSWs ............................................................... 132
Table 5.24 Location of STI Testing and Treatment......................................................................................... 134
Table 5.25 HIV Test and Location of Last HIV Test among FSWs ............................................................. 135
Table 5.26 Reason for Getting and Not Getting HIV Test among FSWs.................................................. 137
Table 5.27 Reason for Not Disclosing HIV Test Result among FSWs ...................................................... 138
Table 5.28 Testing, Consent, Counseling and Receipt of Test Result among FSWs .......................... 139
Table 5.29 HIV Treatment among FSWs ............................................................................................................. 141
Table 5.30 TB Symptom, Testing and Treatment among FSWs ................................................................ 143
Table 5.31 Hepatitis B and C Testing and Treatment among FSWs ........................................................ 144
Table 5.32 FSW’s Exposure to HIV Prevention Program ............................................................................. 146
Table 5.33 Information FSWs Receive from Field Outreach Workers.................................................... 147
Table 5.34 Barriers to HIV Service Access among FSW ................................................................................ 148

xi
Table 5.35 Positivity Rate of HIV, STI, Hepatitis B and C, Chlamydia and Gonorrhea among
FSWs per District/Municipality .............................................................................................................................. 151
Table 6.1 Data Collection and Rate of Participation among Clients......................................................... 153
Table 6.2 Survey Venues of Clients........................................................................................................................ 155
Table 6.3 Age Group and Educational Level of Clients .................................................................................. 156
Table 6.4 Marital Status, Circumcision Status and Health Insurance Coverage of Clients ............. 158
Table 6.5 Clients’ Knowledge about HIV/AIDS, Risk Perception, and Protective Behavior .......... 160
Table 6.6 Reasons Clients Feel At Risk of HIV Infection ............................................................................... 163
Table 6.7 Client’s Sexual Behavior, Condom Use Consistency with Steady Partner and FSWs
and Number of Visit to FSWs in the Last Six Months ..................................................................................... 165
Table 6.8 Client’s Reason for Not Using Condom during Last Sex with FSW ....................................... 167
Table 6.9 Age of First Vaginal and Anal Sex among Clients......................................................................... 169
Table 6.10 Age Clients Started Buying Sex ......................................................................................................... 171
Table 6.11 Sex with Other Partners and Injecting Drug Use among Client .......................................... 173
Table 6.12 STI Testing among Clients, Treatment and Treatment Location ....................................... 175
Table 6.13 Last HIV Test among Clients .............................................................................................................. 177
Table 6.14 HIV Testing and Treatment among Clients ................................................................................. 179
Table 6.15 TB, Hepatitis B and C Test, Result and Treatment among Clients ..................................... 182
Table 6.16 Positivity Rate of HIV, Syphilis, Hepatitis B and C among Clients per
District/Municipality .................................................................................................................................................. 185
Table 7. 1 Data Collection Coverage among PWID.......................................................................................... 186
Table 7. 2 Districts/Municipalities that were Excluded from the Aggregate Data Analysis .......... 187
Table 7. 3 Characteristics of PWID ........................................................................................................................ 187
Table 7. 4 Marital Status and Living Arrangement of PWID ....................................................................... 189
Table 7.5 Employment and Health Insurance Coverage of PWID ............................................................ 190
Table 7.6 PWID’s Knowledge about HIV ............................................................................................................. 191
Table 7.7 Risk Perception and Protective Behavior of PWID ..................................................................... 193
Table 7.8 Age at First Injection and Length of Drug Use among PWID .................................................. 194
Table 7.9 Type of Injectable Drugs Used by PWID.......................................................................................... 195
Table 7.10 Injection Frequency on the Last Day of Injection and Needle Use Practices................. 196
Table 7.11 Injection Venue and Source of Needle for PWID ....................................................................... 197
Table 7. 12 Number of Needles Received from the NSEP Program and Abscess at the Injection
Site ...................................................................................................................................................................................... 198
Table 7.13 Imprisonment due to Substance Abuse and HIV Program Implementation in Prison
.............................................................................................................................................................................................. 199
Table 7. 14 Age of First Sexual Intercourse among PWID ........................................................................... 200

xii
Table 7.15 Ways to Obtain Condom, Places the Sell Condom and Places that Provide Free
Condom ............................................................................................................................................................................. 201
Table 7.16 PWID’s Sexual Behavior and Condom Use with Steady and Non-Steady Partner....... 202
Table 7.17 PWID’s Sexual Behavior and Condom Use with Commercial Sex Partner ..................... 203
Table 7.18 PWID’s STI Symptom, Testing and Location of Last STI Test .............................................. 204
Table 7.19 STI Treatment, Place of Treatment and STI Test Recommendation to Partner........... 205
Table 7.20 HIV Testing and Location of Last HIV Test .................................................................................. 207
Table 7.21 PWID’s Reason for Getting and Not Getting HIV Test ............................................................. 208
Table 7.22 Consent, Counseling and Receipt of HIV Test Result among PWID................................... 209
Table 7.23 HIV Treatment and Viral Load Test among PWID .................................................................... 211
Table 7.24 TB Symptom, Testing, Treatment and Offer of HIV Test ...................................................... 212
Table 7.25 Hepatitis Testing, Prevention and Treatment ........................................................................... 213
Table 7.26 Coverage of Other HIV Prevention Program among PWID ................................................. 214
Table 7.27 Types of Information PWID Received from Field Outreach Workers ............................. 216
Table 7.28 Positivity Rate of HIV, Syphilis and Hepatitis among PWID in each
District/Municipality .................................................................................................................................................. 218

xiii
 LIST OF FIGURES
Figure 2.1 Flow of Questionnaire Verification and Submission ...................................................................16

Figure 3.1 Positivity Rate of HIV, STI and Hepatitis in MSM Respondents ..............................................57

Figure 4.1 Positivity Rate among Waria .................................................................................................................97

Figure 5.1 Positivity Rate of HIV, STI, Hepatitis B and C, Chlamydia and Gonorrhea Aggregate
Data in FSWs ................................................................................................................................................................... 150

Figure 6.1 Positivity Rate of HIV, STI and Hepatitis B and C Aggregate Data in Clients .................. 184

Figure 7.1 Positivity Rate of HIV, Syphilis and Hepatitis in PWID............................................................ 217

xiv
 LIST OF ACRONYMS
ABK Anak Buah Kapal (Ship Crew)
AIDS Acquired Immuno Deficiency Syndrome
ARV Antiretroviral
BNN Badan Narkotika Nasional (National Narcotics Agency)
BPJS Badan Penyelenggara Jaminan Sosial (Social Security Administrator)
CI Confidence Interval
CRS Chain Referral Sampling
DAA Direct-Acting Antivirus
DOTS Directly-Observed Treatment Shortcourse
HIV Human Immunodeficiency Virus
IMS Infeksi Menular Seksual (Sexually-transmitted Infection - STI)
KIE Komunikasi Informasi dan Edukasi (Information Education and
Communication - IEC)
KTHIV Konseling dan Tes HIV (HIV Testing and Counseling – HTC)
KTS Konseling Dan Tes HIV Sukarela (Voluntary Counseling and Testing –
VCT)
LASS Layanan Alat Suntik Steril (Needle and Syringe Exchange Program –
NSEP)
LGV Limphogranuloma Vereneum
MSM Lelaki Seks Lelaki (Men who have Sex with Men)
LSM Lembaga Swadaya Masyarakat (Non-Governmental Organization – NGO)
NAPZA Narkotika, Psikotropika dan Zat Adiktif Lainnya
ODHA Orang Dengan HIV/ AIDS (People who Live with HIV/AIDS – PLHIV)
OKU Ogan Komering Ulu
PDP Perawatan Dukungan dan Pengobatan (Care Support and Treatment –
CST)
PWID Pengguna NAPZA Suntik (People who Inject Drugs)
PKM Puskesmas
PKR Pusat Kesehatan Reproduksi (Center of Reproductive Health)
PL Petugas Lapangan (Field Worker)
PNS Pegawai Negeri Sipil (Civil Servant)
PO Petugas Outreach (Outreach Worker)
PSU Primary Sampling Unit
RDS Respondent-Driven Sampling

xv
RS Rumah Sakit (Hospital)
SD Sekolah Dasar (Elementary School)
SDGs Sustainable Development Goals
SIS Safe Injection Sites
SMA Sekolah Menengah Atas (High School)
SRS Simple Random Sampling
STBP Surveilans Terpadu Biologis dan Perilaku (Integrated Bio-Behavioral
Surveillance – IBBS)
TasP Treatment as Prevention
TB Tuberculosis
TIPK Tes HIV Atas Inisiatif Pemberi Layanan Kesehatan (Provider-Initiated
Testing and Counseling)
TLS Time Location Sampling
TNI Tentara Nasional Indonesia (Indonesian Army)
UHC Universal Health Coverage
UPK Unit Pelayanan Kesehatan (Health Service Unit)
VCT Voluntary Counselling and Testing
Waria Wanita Pria (Women Men)
WHO World Health Organization
WPS Wanita Pekerja Seks (Female Sex Workers – FSWs)

xvi
 EXECUTIVE SUMMARY
The Integrated Biological Behavioral Surveillance (IBBS) 2018-2019 is the fourth IBBS, after
three rounds of surveillance in 2007&2009, 2011&2013, and 2015. The objective of the 2018-
2019 IBBS is to obtain a picture of HIV, STI and Hepatitis prevalence, as well as information about
risk behaviors among at-risk population, and coverage of intervention programs among target
populations.

The 2018-2019 IBBS was conducted in 60 Districts/Municipalities in 23 provinces in Indonesia

among Men who have Sex with Men (MSM), Waria (transgender), Female Sex Workers (FSWs)
and their Clients, also People who Inject Drugs (PWID). Minimum sample sizes were 6000 MSM
from 24 Districts/Municipalities, 5250 waria from 21 Districts/Municipalities, 7200 FSWs from
18 Districts/Municipalities, 9600 clients from 24 Districts/Municipalities and 4180 PWID spread
out in 19 Districts/Municipalities. Respondent-driven sampling (RDS) method was used for the
MSM and PWID groups, while time-location sampling (TLS) method was used for the waria, FSW
and client groups.

Overall, the biological component of the surveillance had a slightly higher participation rate than
the behavioral component. Among all the key populations, people who inject drugs (PWID) had
the lowest participation in the surveillance, 59.6% for the behavioral component, and 60.3% for
the biological component, while clients had the highest participation, i.e. 84.2% for the behavioral
component and 84.9% for the biological component. The participation rate of the other key
populations, MSM, Waria and FSW was 76.6%, 58.2%, 79.1% respectively for the behavioral
component and 77.7%, 59.4%, 79.9% respectively for the biological component.

HIV, STI and Hepatitis Prevalence

The 2018-2019 IBBS records that the highest proportion of HIV, at 17.9%, was detected among
MSM, followed by PWID (13.6%), waria (11.9%) and FSW (2.1%). The client group had the lowest
proportion of HIV (1.1%). In terms of sexually-transmitted infection, there were more acute
infections of chlamydia and gonorrhea than syphilis. Almost one-third of FSW and MSM were
infected with chlamydia (31.1% and 27.1% respectively), while waria had a lower rate of
infection (13.9%). For gonorrhea, the highest rate of infection was among MSM (17.8%). For
waria and FSW, about one every ten respondents suffered from gonorrhea (8.6% and 11.4%
respectively).

In this 2018-2019 IBBS only a small percentage of respondents had hepatitis B or C, except for
the PWID group with a 30.8% prevalence. The highest proportion of Hepatitis B was detected
among MSM (5.1%) and the lowest was found among FSWs (1.0%). The prevalence of Hepatitis

xvii
B in the other groups - waria, clients and PWID - ranged between 1.8%-2.9%. The prevalence of
Hepatitis C among MSM, waria, FSW and clients ranged between 0.2% - 1.6%.

Demographic Characteristics

In general, respondents from all key populations were relatively young. The majority were
between 25 – 49 years of age (50.4% - 74.7%), and the rest were younger, between 20 to 24 years
old (14.3% - 29.0%). Most respondents from all key populations have completed high school or
an equivalent level of education, but interestingly, in each key population there still are
respondents who never went to school. The highest percentage was among waria (1.6%) and the
lowest was among MSM (0.4%).

For marital status, each key population showed a different pattern. The MSM, Waria, and PWID
were mostly unmarried (81.9%, 92.1% and 46.1% respectively), while the majority of FSWs
(44.4%) were divorced, and half of the clients (51%) were married and were living with their
spouse.

Another characteristic that was looked at was respondents’ living arrangement. Most of the MSM
and PWID still lived with their family or sibling (54.8% and 59.9% respectively), while the
majority of Waria and FSWs lived alone (43.2% and 24.4%).

In terms of employment, the MSM group was one whose members were mostly employees with
a steady income (36.0%). The Waria and PWID generally do non-formal jobs (43.6% and 35.5%),
while around one-third (34.1%) of FSWs also hold other jobs and do not rely exclusively on sex
work for income.

Regarding health insurance, the group with the least coverage, either through public or private
insurance, was Waria (64.6%). At 59.8% and 55,9% respectively, MSM and PWID were two key
populations that have the highest participation in BPJS, the public insurance, while 66% of the
Clients have insurance but detailed information about the type of insurance was not available.

Knowledge and Risk Perception

Level of knowledge about HIV varied among key populations, the highest was among the PWID
(57.4%) and the lowest was among the FSWs (16.0%). This survey defines comprehensive
knowledge as knowing a set of basic information on HIV prevention, and mode of transmission,
also knowing that an individual can be infected with HIV and still looks healthy.

Overall most respondents had a relatively high level of risk perception, except for the clients at
only 37.6%. Waria and PWID had the highest risk perception (74.8% and 71.2% respectively)
than the other key populations.

xviii
Sex Behavior and Condom Use

Risk behavior was evaluated through an individual’s use of condom during the last sex encounter,
and consistency in condom use during sex in the last month. Condom use was highest among MSM
who is also the group with the largest number of sex partners. Condom use in the last sex
encounter was highest with a male casual non-steady partner (69.9% of the 47.4% MSM who
have male casual partners), and was most consistent during paid sex in the last month (51.0% of
the 25.0% MSM who sell sex to men).

Waria had a similar pattern of condom use with MSM. From the 59.1% Waria who have casual
non-steady male partners, three-quarters (74.6%) used condom in their last sex encounter,
which was the highest percentage of all. Condom use was also quite consistent, 63% during sex
with a casual partner, and 62.6% during paid sex (from the 59.4% waria who sell sex).

In the FSW group, condom use was highest (66.8%) and most consistent (67.8%) during
commercial sex. In sex with a steady partner however, condom use sharply decreased to 22.9%
in the last sex, and only 15.5% in consistency in the last month.

PWID had quite a different pattern. Consistent condom use was highest during commercial sex
(the respondent bought sex from women). Out of the 13.9% PWID who buy sex, 47.3% used
condom in their last sex encounter. The same percentage was also found for consistency in
condom use.

Clients of sex workers behaved differently. Only 48.1% used condom with FSW, and only 35.8%
used condom consistently.

Coverage of Prevention Program

HIV prevention program has not been able to reach a significant proportion of key population.
During meetings/discussion on HIV/STI prevention with service providers, the most actively
participating group has been the PWID (42.8%) who also received the most printed and audio-
visual prevention materials (42.1%). The least active group has been the FSW. Only 12.9% of
them attended discussion meetings with service providers, while those who received prevention
IEC materials was a similarly low proportion (12.8%). FSWs also received the lowest number of
free condom (22.3%) that were distributed by various prevention programs, while the waria
group was the one who received the most condoms (59.6%). Efforts by service providers to visit
or contact members of key populations have been limited. The 2018-2019 IBBS shows that
current prevention programs are only able to reach 10.7% of waria, 9.9% of MSM, 6.5% of PWID
and 2.8% of FSWs.

xix
 Introduction
1.1 Background
Globally the Human Immunodeficiency Virus (HIV) epidemic continues to pose a serious public
health problem. In Indonesia, the HIV prevalence is estimated to be around 0.32%, but since the
1990s, the proportion has been steadily and significantly increasing in several high-risk
population groups, primarily among female sex workers, men who have sex with men and waria
(HIV Epidemic Model, 2015).

To obtain information about the prevalence of HIV among the general population, HIV
surveillance was initiated. Sero-surveillance had been performed since 1988, while behavioral
surveillance started in 1996. Subsequently, the two types of surveillance were combined to form
an integrated second-generation bio-behavioral surveillance. A concept of sentinel population
was also introduced to represent existing sub-populations who are at-risk of infection. Currently
there is a plan to further expand the existing program to include surveillance on HIV incidence,
on pediatric and adult PLHIV (people who live with HIV/AIDS) and their access to antiretroviral
therapy (ART), on treatment adherence and decrease in AIDS-related deaths.

As generally known, to gain a better understanding of the epidemic dynamics and key
determining factors that play a role in the speed of HIV transmission, in 2006 the Integrated
Biological and Behavioral Surveillance (IBBS) was launched. Data obtained through this
surveillance was able to more comprehensively illustrate the magnitude of the problem, the
causative factors, people’s knowledge about the disease and their response toward that
knowledge. A picture also emerged about the situation among the population who was most-at-
risk of infection, and it was then decided to continue conducting the IBBS regularly. IBBS was then
conducted in 2009, 2011, 2013, and 2015 in 2 different regions.

The 2018 IBBS is designed to capture the national prevalence of HIV, so the number of
respondents, and survey sites (districts/municipalities, and provinces) was increased. In West
Java, the IBBS also looked at the prevalence of Hepatitis B and C, as they share a similar mode of
transmission as HIV and STIs and can be prevented through similar measures as well. Populations
who are at-risk of HIV and STI infection are also at-risk of getting Hepatitis B and C.

To successfully prevent HIV infection, there needs to be a change of behavior, from high-risk to
lower-risk behavior. This survey combines data from biological examination with information
about changes in risk behavior that includes higher use of condom and fewer sex partners among
those who are sexually-active, decreased sharing of needles among PWID, increased access to
methadone maintenance treatment (MMT) and delaying sexual intercourse among the youth.

1
1.2 Objectives
The IBBS aimed to achieve the following objectives:
a. Determine the prevalence of Gonorrhea, Chlamydia, Syphilis and HIV among most-at-risk
populations in several cities in Indonesia.
b. Determine the level of knowledge and perception about HIV transmission and prevention in
high-risk populations.
c. Determine the level of behavior that will put individuals at risk of acquiring/transmitting HIV
among high-risk populations in several cities in Indonesia.
d. Measure the coverage of HIV and sexually-transmitted infection (STI) control interventions
and their impact on Ministry of Health target populations.
e. Determine the prevalence of Hepatitis B and C in high-risk population in West Java.
f. Determine the level of knowledge and perception about Hepatitis B and C transmission and
prevention among high-risk population in West Java.

2
 Method
2.1 Survey Design
The 2018 IBBS was conducted using a cross-sectional design, where all variables were observed
and simultaneously tested. It is hoped that this design can facilitate determination of the national
prevalence of HIV, STI, and Hepatitis in each key population.

2.2 Survey Location

The IBBS was conducted in 23 provinces, 60 Districts/Municipalities, i.e. Aceh (Aceh Besar,
Banda Aceh City, Semeuleu, East Aceh), North Sumatra (Pematang Siantar City), Riau Islands
(Tanjungpinang City, Batam City), Bangka Belitung (Pangkal Pinang City), South Sumatra
(Palembang City, Ogan Komering Ulu (OKU), Prabumulih City), West Sumatra (Bukittinggi City,
Padang City), Lampung (Bandar Lampung City), Banten (Tangerang, South Tangerang City,
Cilegon City), DKI Jakarta (West Jakarta City, South Jakarta City, East Jakarta City, Seribu Islands),
West Java (Bogor City, Bogor, Bekasi City, Bekasi District, Bandung City, Depok City, West
Bandung, Sukabumi City, Sukabumi, Purwakarta), Central Java (Surakarta City, Pekalongan City,
Tegal City, Salatiga City, Banyumas), DIY (Yogyakarta City), East Java (Surabaya City, Banyuwangi
District, Sumenep City, Mojokerto City, Blitar City, Probolinggo City, Pamekasan, Madiun City),
Bali (Denpasar City, Gianyar, Buleleng, Badung), South Sulawesi (Makassar City), North Sulawesi
(Menado City), West Kalimantan (Pontianak City), East Kalimantan (Balikpapan City), Central
Kalimantan (Palangkaraya City), NTT (Kupang City), NTB (North Lombok), Maluku (Ambon City,
Maluku Tenggara Barat), Papua (Jayapura City, Puncak).

2.2.1 Consideration in Survey Location Selection

The survey was performed in selected districts/municipalities. Exclusion criteria were: difficult
to access area such as those with security issues that will hamper timely completion of data
collection, or areas with very few members of target population as determined through mapping
performed prior to the survey. In the initial stage, districts/municipalities were listed along with
key population size based on the 2012 estimate for FSW and PWID, 2016 estimate for MSM and
Waria. Then districts/municipalities were divided into 6 (six) groups based on the result of
hierarchical cluster analysis. Districts/municipalities were selected at random with attention to
the opportunity for selection. The following districts/municipalities were then generated.

3
 Table 2.1 Number of Selected Districts/Municipalities for Each Key Population

MSM PWID Waria FSW

Group Total Total Total Total Total Total Total Total
KK Selected KK KK Selected KK KK Selected KK KK Selected KK
1 362 12 1 1 1 1 3 1

2 5 1 1 1 3 1 81 5

3 11 2 1 1 76 4 13 2

4 114 5 3 1 3 1 2 1

5 1 1 305 10 2 1 1 1

6 18 3 41 5 380 13 412 8

Total 511 24 352 19 465 21 512 18

KK=Districts/Municipalities

2.3 Population
The 2018 IBBS specifically targeted key populations because relative to other groups in the
population, these key populations are likely to have a larger contribution to the transmission of
HIV, STI and Hepatitis. The targeted key populations were PWID, Waria, Men who have Sex with
Men (MSM), Female Sex Workers (FSW) and Clients of sex workers. The IBBS defines key
populations as follows:
• Men who have Sex with Men (MSM) are men who have sex with men, either once,
occasionally, or routinely.
• People who Inject Drugs (PWID) are people who use drugs by injection for non-medical
purposes.
• Waria is an abbreviation of wanita-pria (female-male), which means a person who was
biologically born as male, but identifies as female or Waria.
• Female Sex Workers (FSW) are women who sell sex as their main or additional source
of income, and receive payment in the form of money, goods or favor.
• Clients of FSW are men who have sex with FSW, either occasionally or regularly.

2.4 Samples
Survey samples were members of key population who fulfill the following inclusion criteria:

• Men who have Sex with Men (MSM) are men who are at least 15 years of age, have had
sex with men at least once within the last year, and have lived in the survey city for at least
one month.
• People who Inject Drugs (PWID) are men or women who are 15 years old or older who
use drugs by injection for non-medical purposes at least once in the last year and have
lived in the survey city for at least one month.

4
 • Waria are men aged 15 years old or older who identify as women or waria, have had sex
with men at least once in the last year, and have lived in the survey city for at least one
month.
• Female Sex Workers (FSW) are women who are at least 15 years old, sell sex as their
main or additional source of income, and receive payment in the form of money, goods or
favor. The women also had sex with at least one client in the last month, were in the survey
location at the time of survey team’s visit, and have lived in the survey city for at least one
month.
• Clients of FSW are men who are 15 years or older, have had sex with FSW in the last 3
(three) months.

2.4.1 Sample Size

The minimum sample size needed for the 2018 IBBS to estimate the proportion of diseases with
absolute precision was calculated using the following equation:

n : Minimum number of samples per key population per location

D : Design effect
Z1-α : Z value at 95% CI, i.e. 1.96
P : the expected proportion
d : Precision

Table 2.2 Sample Size for Each Key Population

No Key Population n D P d Z1- α Non response

1 MSM 250 1.5 0.22 0.066 1.96 0.1
2 PWID 223 1.5 0.24 0.072 1.96 0.1
3 Waria 250 1.5 0.22 0.066 1.96 0.1
4 FSW 397 1.5 0.06 0.03 1.96 0.1

Using the above formula, and a non-response rate set at 10%, the minimum sample size for each
key population was calculated. The total sample that would need to be collected for each key
population in each selected survey site is as follows:

Table 2.3 Total Samples for Each Key Population

Key Population Total Samples Number of Selected Districts/Municipalities Target Samples

MSM 250 24 6000
PWID 220 19 4180
Waria 250 21 5250
FSW 400 18 7200
Client 400 24 9600

5
2.5 Sample Collection Method
The 2018 IBBS utilized two different sample collection methods, i.e. Time-Location Sampling
(TLS) for Waria, FSW and their Clients, and Respondent-Driven Sampling (RDS) for MSM and
PWID.

2.5.1 Time-Location Sampling (TLS)

TLS is a widely-used sample collection method for populations that are “floating” (i.e. are less
likely to be found by enumerators at a fixed place). TLS is a venue-based sampling that is based
on clusters. The primary sampling unit (PSU) is a combination between location and time, and
the same location can be included in the sampling frame more than once but at different time
periods.

The first step in selecting sample locations using the TLS method is to make a list of locations and
time periods candidate respondents are expected to be at those locations. Afterwards, time slots
are determined, which will be the basis for setting the primary sampling unit. As mentioned
earlier, in the TLS method, one location can be selected more than once if there are more than one
time period when target populations gather at that location.

Strengths and Limitations of TLS

Strengths
• It is considered as representative or approximates random cluster sampling
• It is efficient for rare or hard-to-reach population
• It does not require a complete list of individuals in the key population of interest

Limitations
• It needs a complete “map” of locations and timing
• It is quite hard to validate
• It results in bias toward those who are present on the locations, but will not include those
who do not regularly come to the locations

Selection of Respondents
Sample selection was performed using simple random sampling (SRS) as follows:
a. Count the population that are already present at the selected location and time.

b. Wait 15 minutes to confirm the total available population (to anticipate any movement into
and out of the location).

6
c. At each location and time period, choose eight respondents based on simple random
sampling method (see previous description about SRS).
d. Based on the SRS method, randomly choose two FSW or Waria from the people at the
location.
e. Choose the next two respondents from FSWs or Waria who just arrive at the location after
interview has proceeded for 60 minutes.
f. The next respondents are chosen from two FSWs or Waria who just arrive at the location
after interview has proceeded for 120 minutes.
g. After completing the interviews, the interviewer will do another randomization using the SRS
method (see previous description about SRS method) and choose two FSW or Waria who just
arrive in the last 180 minutes to participate in the survey. The supervisor HAS TO record the
number of FSW or Waria who were present at the location during the specific time period,
the number who participated in the survey, and the number who refused to participate.

Substitution of Respondents
Substitution was performed when the targeted number of respondents could not be reached due
to refusals, or other conditions (menstruation for FSWs, illness for waria) that caused the
individual to be ineligible as a respondent. To extent possible, substitute respondents were
selected from the same target population, of the same type of location that is closest to the original
location/venue/hotspot.

Substitution could only be decided by a supervisor based on a report from the interviewer using
the STBP18-PW-1 Form or interviewer’s daily log. Interviewers were not allowed to perform
substitution of respondents. A supervisor subsequently reported the number of prospective
respondents who refused to participate at each selected location under his responsibility using
the STBP18-PG-3 Form. In addition to collecting interviewer’s daily log (STBP18-PW-1),
summarizing the content into STBP18-PG-3 Form, a supervisor also completed an attendance list
or STBP18-PG-1 Form.

2.5.2 Respondent-Driven Sampling (RDS)

The Respondent-Driven Sampling (RDS) method is part of Chain Referral Sampling (CRS) similar
to Snowball Sampling and Network Sampling. The advantage of the RDS method is that it allows
collection of probabiliy samples in order to perform statistical analysis including calculation of
standard error. The RDS method is used to capture information from hard-to-reach or hidden
populations whose risk behavior cause them to “hide” or camouflage themselves as part of the
general population.

RDS is a snowball sampling technique based on a recruitment quota and dual incentives to
motivate recruiters and the recruited people. Through this method one does not need to recruit

7
the whole sample from a limited number of individuals. The seeds participate in the survey as
recruitment wave zero. These seeds will recruit individuals and start the first wave of recruitment
and the process continues from there. In theory, sample homogeneity can be achieved after at
least 3 recruitment waves. RDS starts with a small number of participants called seeds who are
recruited purposively. Attempts to select heterogeneous seeds should be made to ensure that any
random member of the target population has the probability to be recruited. To provide access
to all the respondents, it is critical to ensure that the clinic remains open during weekends.

The RDS for PWID started with 3 seeds who received the first coupons. These seeds were people
who support the objective of this survey and would be able to motivate other people to participate
in this activity. To the extent possible the seeds were also of different age groups, gender,
residence, socio-economic status, etc.

Initially 3 seeds were recruited with the possibility of adding more seeds when the targeted
number of samples was not yet reached close to the survey deadline. Seeds were selected by an
NGO staff who works with the target population. Seeds were ideally people who are known and
accepted by members of the target community. They should also support the objective of this
survey and were able to encourage and motivate other people to participate in the survey. In
general, members of the target population who were workers were proposed to serve as seeds.
In this survey, 3 seeds were first recruited in each location. Each seed was given 3 coupons and
asked to recruit 3 more PWID to participate in the survey.

Attempts were made to recruit seeds of various ages, from different neghborhoods in the survey
city and from a variety of socio-economic background. For example, in City X, seeds were selected
from each hotspot area in different regions throughout City X.

2.5.3 Sampling Framework Construction

The TLS method in principle is of a similar concept as simple random sampling. Sampling
framework was therefore needed for sample selection, and mapping was performed in order to
construct a sampling frame. Data needed for mapping was as follows:

• Data on localization, brothel or other data on female sex workers from the District Social
Affairs Office, District Health Office or local NGOs.
• Data on massage parlor, pub, karaoke bar, hotel, motel, apartment, guest house, salon, etc
from the local Tourism Office and other informal sources.
• Data from formal and informal sources or partner NGOs.
• Data or other information from formal and informal sources that can be used to construct a
sampling frame such as electronic and printed media, and community groups who have
concerns about HIV/AIDS issues like non-governmental organization or foundation that is
involved in HIV/AIDS intervention activities.

8
Sampling Frame for FSW
The sampling frame for FSWs was a list of FSW locations and estimates of population size at each
location (roadside, railway track, park, cemetery, motel, café, brothel, hotel, massage parlor/spa,
karaoke bar, pub and restaurant).

The sampling frame included details about the day, timing, number of FSWs, and times that were
suitable for interview. The information was obtained through inventory, and field exploration
performed in the mapping activity. Key contact persons along with their contact information were
also recorded for communication during the day of interview.

Sampling Frame for Waria

The sampling frame for waria was a list of locations where waria often gather, both those who
work as sex workers and those who do not. Locations included salon, road intersections where
waria work as street-based singer, etc. The sampling frame also included information about the
estimated number of waria at each location, name and contact information of key contact person
at each location and the most suitable time for interview. Data and information were obtained
through inventory and field exploration during mapping.

Sampling Frame for Clients of Sex Workers

The sampling frame for FSW’s clients followed the FSW’s sampling frame, which contained a list
of FSW locations on each specific day and time, along with estimates of population size at each
location (roadside, railway track, park, cemeteries, motel, café, brothel, hotel, massage
parlor/spa, karaoke bar, pub and restaurant).

Table 2.4 Total Samples for each Key Population at each 2018-2019 IBBS Survey Location
Key Population
No Province District/Municipality
FSW Waria MSM PWID Clients
1 Aceh Aceh Besar 250
Banda Aceh City 220
Semeuleu 400 250
East Aceh 250
2 North Sumatra Pematang Siantar City 250
3 Riau Islands Tanjung Pinang City 250
Batam City 400 250 400
4 Bangka Belitung Pangkal Pinang City 400 400
5 South Sumatra Palembang City 250
Ogan Komering Ulu
(OKU) 400 400
Prabumulih City 250
6 West Sumatra Bukittinggi City 400 400
Padang City 220
7 Lampung Bandar Lampung City 250 250 220

9
 Key Population
No Province District/Municipality
FSW Waria MSM PWID Clients
8 Banten Tangerang 250 220
South Tangerang City 220
Cilegon City 250
9 DKI Jakarta West Jakarta City 400 250 400
South Jakarta City 400 250 400
East Jakarta City 220
North Jakarta City 400 250 400
10 West Java Bogor City 250
Bogor 250 250 220
Bekasi City 400 220 400
Bekasi District 250 400
Bandung City 220
Depok City 400 250 250 220 400
West Bandung 220
Sukabumi City 400 220 400
Sukabumi 220
Purwakarta 250
11 Central Java Surakarta City 250
Pekalongan City 400 400
Tegal City 250
Salatiga City 220
Banyumas 250
12 DIY Yogyakarta City 250 250 220 400
13 East Java Surabaya City 400 250 400
Banyuwangi 250
Sumenep City 400 250 400
Mojokerto City 250 250
Blitar City 250 220
Probolinggo City 250
Pamekasan 250
Madiun City 250 400
14 Bali Denpasar City 250 400
Gianyar 400 400
Buleleng 250
Badung 220
15 South Sulawesi Makassar City 220 400
16 North Sulawesi Manado City 250 400
17 West Kalimantan Pontianak City 250
18 East Kalimantan Balikpapan City 400 400
19 Central Kalimantan Palangkaraya City 250
20 NTT Kupang City 250 220 400
21 NTB North Lombok 250
22 Maluku Ambon City 250
Maluku Tenggara Barat 400 400
23 Papua Jayapura City 400 400
Mimika 250

10
The above table lists the total samples that were collected for the behavioral and biological components of
the IBBS. Data collection flow in the 2018 IBBS was as follows:

For MSM and PWID

RDS Fee and

Collection of
Seed Interview Coupon for the
Biological Samples
next 3 people

Graph 1 Data Collection Flow for MSM and PWID

For Waria, FSW and Clients

Target Group Selected Respondents Interview

Incentive and Coupon

Pick up for Survey Collection of Biological
Participation Samples

Graph 2 Data Collection Flow for Waria, FSW and Clients

2.6 Data Collection Instrument

Data collection in the 2018 IBBS used two primary instruments: behavioral quesionnaire and RDS
coupon. Several other forms were also prepared to monitor data collection activities.

Behavioral Questionnaire

The behavioral questionnaire was divided into five types, one for each key population. Questions
that were included in the questionnaire are listed in the table below.

11
 Table 2.5 Topic of Questions in the Behavioral Questionnaire

No Variables MSM PWID Waria FSW Client

1 Consent after receiving explanation √ √ √ √ √
2 Site introduction √ √ √ √ √
3 Interviewer’s explanation √ √ √ √ √
4 Network Size √ √ x x X
5 Respondent’s Characteristics √ √ √ √ √
Knowledge about HIV/AIDS, Risks and
6 √ √ √ √ √
Prevention
√ √
7 Condom and Lubricant √ (only √ (only √
condom) condom)
8 Injectable drugs x √ x √ √
9 Sexual behavior √ X √ √ X
a. Steady male partner √ X √ √ X
b. Non-steady/casual male partner √ X √ √ X
c. Buy sex from men √ X √ X
d. Sell sex to men √ X √ √ X
e. Waria partner √ X x x X
f. Steady female partner √ √ x x √
g. Non-steady/casual female partner √ √ x x √
h. Buy sex from women √ √ x x √
i. Sell sex to women √ √ x x X
10 Length of time in sex work X X X √ X
11 Client’s occupation X X X √ X
12 Number of clients X X X √ X
13 Sex under duress /coerced sex X X X √ X
14 Sex party √ X x X X
Alcohol consumption and substance
15 √ X √ √ √
abuse
Other risk behavior (tattoo and √ X √ X
16 X
piercing)
17 Program Coverage √ √ √ √ X
a. HIV √ √ √ √ √
b. STI √ √ √ √ √
c. TBC √ √ √ √ √
d. Hepatitis √ √ √ √ √
e. Other prevention program √ √ √ √ X
f. Social media program √ X √ √ x

Monitoring Form

Monitoring forms were used to monitor the collection, shipment and testing of biological
specimens. Three types of form were used: sample shipment form, sample collection form and
laboratory test result recording form.

12
2.7 Biomarker and Laboratory Test
Biological specimens collected were venous blood, vaginal smear/swab (for women) and anal
swab (for men). Syphilis, HIV, Hepatitis B and C tests were performed at appointed Regional
Public Health Laboratories, while testing for Chlamydia trachomatis (CT) and Neisseria gonorrhea
(NG) using polymerase chain reaction (PCR) methodology was performed at the IBBS National
Referral Laboratory appointed by the Ministry of Health in Jakarta.

Table 2.6 Biological Specimen Collection and Testing in each Key Population
Blood
No Key Population Swab Test Note
Sample
Syphilis (RPR and Rapid Vaginal and anal swabs were
TP), Anti-HIV, Hepatitis B sent to the National Referral
1 MSM Venous blood Anal swab
and C. Laboratory for CT/NG test
CT and NG using PCR technology

Syphilis (RPR and Rapid

2 PWID Venous blood Anal swab TP), Anti-HIV, Hepatitis B N/A
and C

Syphilis (RPR and Rapid TP),

3 Waria Venous blood Anal swab Anti-HIV, Hepatitis B and C. Vaginal and anal swabs were
CT and NG sent to the National Referral
Syphilis (RPR and Rapid TP), Laboratory for CT/NG test
4 FSW Venous blood - Anti-HIV, Hepatitis B and C. using PCR technology
CT and NG

Syphilis (RPR and Rapid TP),

5 Client Venous blood - N/A
Anti-HIV, Hepatitis B and C
NA: Not Applicable. Chlamydia trachomatis/Neisseria gonorrhea (CT/NG) test was not performed for these groups

The number of biological specimens that were collected for HIV and syphilis test matched the
number of respondents who were interviewed at each survey location, while CT/NG and Hepatitis
tests were performed in selected locations only. Samples that were collected for biological test
are listed in the following table.

Table 2.7 Biological Specimen Collection Sites for each Key Population

HIV Syphilis CT/NG Hepatitis

Simeuleu
Bogor
Aceh Timur
MSM Bogor City
Depok City
Depok City
In each District/Municipality Yogyakarta City
the location of behavioral data
collection Bogor, Sukabumi, West Bandung,
PWID NA Sukabumi City, Bandung City,
Bekasi City, Depok City
Aceh Besar, Bekasi, Surabaya Bogor, Purwakarta, Bekasi, Depok
Waria
City City

13
 HIV Syphilis CT/NG Hepatitis
Simeuleu, Balikpapan City,
Sukabumi City, Bekasi City, Depok
FSW Gianyar, West Jakarta City,
City
Bekasi City, Sumenep
Bekasi, Sukabumi City, Bekasi City,
Client NA
Depok City
NA: Not Applicable; Chlamydia trachomatis/Neisseria gonorrhea (CT/NG) test was not performed for these groups

2.8 Data Collection

Data collection followed a series of activities that were divided into pre-data collection, data
collection, and post-data collection. Each stage was coordinated by a specific person-in-charge.
Stages of activities, timing and persons in charge are detailed in the following table.

Table 2.8 Stages of Activities in 2018-2019 IBBS

No Stage Activity Timeline Location Person-in-Charge

Preparation for Data Collection

Develop:
1. IBBS Module,
Module Preparation 2. Module on methodology, sampling and
1 Training and preparation RDS,
of IBBS package 3. Interview guide,
4. Biological specimen collection guide,
5. Field implementation procedure.

TOT for central-level instructors (biological

At the central
2 Training and behavioral component, field coordinator
level
and day-to-day supervisor)

Train district/municipality day-to-day

implementor/manager, supervisor,
In each
3 interviewer and biological specimen
province
collection staff, admininistration, finance,
logistics staffs, coupon manager

Recruit interviewer and biological specimen

4
collection staff

Prepare human resources who will be

involved in the implementation of 2018 IBBS:
district/municipality day-to-day manager,
Preparation of resources, Field coordinator
supervisor, interviewer and biological
5 equipment and materials and day-to-day
specimen collection staff, coupon manager,
in each survey site Manager
selector, navigator/key contact person,
laboratory staff, admininistration, finance,
logistics staffs.

Socialization at survey locations is necessary

Field Coordinator
to facilitate the data collection process.
and District/
Socialization should involve local
6 Municipality day-
Conditioning at survey stakeholders at the selected locations
to-day Manager,
sites (civilian police, related government offices /
Supervisor
institutions, NGOs)

7 Construct a list of locations

Data Collection

14
 No Stage Activity Timeline Location Person-in-Charge

Interview respondents
Collection of behavioral
8 Complete interviewer’s daily log Enumerator
data
Upload interview results onto the online and offline application
Data Management
9 Upload questionnaires Upload interview results to the server Team and
Supervisor
Specimen
10 Collect specimen
Collection Staff

11 Gather, pack and send specimens Supervisor

Collection of biological
12 Test specimens Laboratory Staff
specimen and data

13 Submit data to the data management team

Data Management and Analysis

Data Management
14 Data Management Editing dan Cleaning Data
Team

15 Data Analysis Data Analysis September – November 2019 Data Analysis Team

17 Report writing Write the 2018-2019 IBBS report November 2019 Data Analysis Team

2.9 Data Management

Management of 2018 IBBS data was done in stages, with a separate responsible person for each
stage. The process starts with data collection, data checking and verification, data entry, data
cleaning and preparation for analysis.

2.9.1 Data Processing

The 2018/2019 IBBS data was collected by trained enumerators for the behavioral component,
while biological specimens were collected by trained specimen collection personnel after
collection of behavioral data. The 2018-2019 IBBS used electronic questionnaire so enumerators
entered data directly to a pre-installed IBBS application on a tablet/mobile phone. The data would
be received and checked by a supervisor and subsequently sent to a central server for editing and
cleaning by a data management team.

Data Checking

At this stage, data from enumerators would be reviewed and checked for completeness or errors.
Any mising data would be verified with possible re-codification. Data submission started from
the enumerator to a field supervisor for review. If a mistake was detected, the supervisor would
request the enumerator to make the necessary correction and resubmit the form for another
review, and once verification was completed, the supervisor would ask the enumerator to upload
the questionnaire to the central server. Data verification and submission is illustrated in the
following flowchart.

15
 Completed
Kuesioner yang Uploading
Pengiriman
questionnaires from
telah diisi oleh Central
the enumerator
enumerator Server Pusat
Server

Perbaikan
Revision

Checking
Pengecekan

Field
Pengawas
Supervisor
Lapangan

OK
Figure 2.1 Flow of Questionnaire Verification and Submission

Data Editing

Data editing was performed by the data management team who would check for any data entry
errors. For example, to a question on the year of first sexual intercourse, some enumerators
would enter the respondent’s age. Data editing would be done by subtracting the age of first sex
from the respondent’s current age to obtain the difference. Data would then be re-entered.

Transformation of Variables

Transformation of variables was done for certain cases. The objective was to change the
measurement scale of the original untransformed variables into another format so that the data
could fulfill the assumptions that underlie an analysis. To do this, variables were re-grouped/re-
coded to match the goal of analysis.

Data Cleaning

Data cleaning was performed to:

1. Ensure no data was missing. A method was used to detect any missing data by constructing
a list (distribution frequency) of all the variables. The distribution frequency table would
enable identification of any missing values.

2. Detect data variations. Data variation would enable detection of incorrect data. Categorical
data that was entered would be explained by the distribution frequency of each variable, and
any coding mismatch would be recognized.

3. Recognize data consistency. This would be done by comparing two tables or by making a
cross-tabulation.

16
2.9.2 Data Quality

Quality assurance of the data was performed by field supervisors, data management team and
data analysis team. Analysis was done on data that had undergone a series of cleaning and editing
process to ensure that the analyzed data were accurate and logical.

2.9.3 Data Analysis

Analysis of 2018-2019 IBBS data was done using multivariate analysis to determine the risk
factor for HIV and syphilis infection in each key population. In univariate analysis weighting was
not possible due to inavailability of data about population cluster and key populations in each
cluster. Univariate analysis results were presented as an aggregate per District/Municipality.
Aggregate data were combination of data from Districts/Municipalities that had sufficient
number of samples, while Districts/Municipalities with a small number of samples were taken
out of the aggregate calculation.

Data was presented as a proportion per category (for categorical data) and median or mean value
(for numerical data).

Data analysis was performed by the 2018-2019 IBBS data analysis team.

2.10 Ethical Approval

The 2018-2019 IBBS was submitted and presented to the ethics committee of the Faculty of Public
Health, University of Indonesia and received approval number 727/UN2.F10/PPM.00.02/2018.
During the survey, informed consent was obtained from every respondent based on the principle
that a competent individual is entitled to freely choose to participate or not participate in the
study. Informed consent realizes an individual’s freedom to make a choice and respects the
individual’s autonomy. In this survey, informed consent was obtained through the following
process:

a. Explain about the study starting with an introduction of the interviewer, the survey
objective, and the institution the interviewer represented;
b. Provide information about the approximate time needed for the interview;
c. Provide information about the topics of questions that would be asked;
d. Explain that participation in the study is voluntary, and respondents can choose to not
respond to some or all of the questions, and can stop the interview at any moment without
pressure or force;
e. Inform respondents that their personal identity and any information provided will be
kept confidential;
f. Provide information that participation in the survey is not linked with any type of service
or favor from any party;

17
Before starting the interview, the interviewer provided time for the respondent to ask questions
or request clarification. Javanese language was used so respondents could better understand the
explanation. Consent was documented as respondent’s signature on the questionnaire.

2.11 Report Layout

The survey report is divided into four parts:

Part 1. Introduction

This part contains the background and objective of 2018/2019 IBBS.

Part 2. Methodology

This part explains about the survey design, sample size calculation and sample collection process,
data collection instrument, biomarker and laboratory testing, field data collection, ethical
approval, data management and report layout. The data management section describes the data
collection process, data quality assurance and analysis.

Part 3. 2018-2019 IBBS Results for each Key Population

This part contains the result of the 2018-2019 IBBS for each key population, plus results of some
special analysis. For each key population, descriptive analysis and multivariate analysis results
are presented. Descriptive data includes demographic characteristics, knowledge about HIV and
prevention intervention, risk perception, sex behavior, program coverage, exposure to
communication for behavior change intervention, also prevalence of HIV, STI and Hepatitis.

The special analysis contains the aggregate results for global indicators, i.e. 1. The HIV Continuum
of Care or Test and Treatment Cascade, 2. The Global Fast-Track Indicator, Global AIDS
Monitoring Indicator, HIV Co-infection with other diseases, HIV and Syphilis Trend Analysis
based on the 2007, 2011, 2015 and 2018 IBBS data, HIV incidence estimate based on proxy
variables and of HIV positive case profiles.

Part 4. Study Limitation

This part describes the limitations in the 2018-2019 IBBS data collection process that may reduce
the validity of collected data.

Part 5. Conclusion and Recommendation

This part contains the conclusion and recommendations based on the 2018-2019 IBBS findings.

18
 Men who Have Sex with Men (MSM)
This chapter explains the survey findings in the MSM group, which consists of the prevalence of
HIV, Syphilis, Chlamydia, Gonorrhea, Hepatitis B and C. Some characteristics of MSM respondents
that relate to risk factors are also described, i.e. level of knowledge, risk perception, risk behavior
and access to health facility.

For the 2018-2019 IBBS, the minimum number of respondents that was determined for the MSM
group was 250 people in each selected District/Municipality. Data was collected from 24
Districts/Municipalities, so the survey expected to recruit minimally 6000 respondents.
Unfortunately, only 4596 respondents participated in the behavioral component of the survey
(data collection coverage of 76.6%) and only 4660 respondents took part in the biological
component of the survey (data collection coverage of 77.7%). Detailed number of respondents
that was planned and actually recruited in each District/Municipality is listed in the table below.

Table 3.1 Data Collection Coverage among MSM

Behavioral Data Biological Data
District/
No Province Plan Actual # of Coverage Actual # of Coverage
Municipality
Respondents (%) Respondents (%)
1 Simeulue 250 79 31,60 71 28,40
NAD
2 East Aceh 250 66 26,40 69 27,60
3 Lampung Prabumulih City 250 250 100 250 100,00

4 Bandar Lampung 250 250 100 250 100,00

City
5 Kep. Riau Batam City 250 250 100 250 100,00
6 DKI Jakarta South Jakarta City 250 238 95,20 250 100.00

7 250 (Seribu
North Jakarta City 246 98,40 250 100,00
Island)
8 West Java Bogor 250 258 103.20 250 100.00
9 Bogor City 250 242 96.80 250 100.00
10 Depok City 250 250 100 250 100.00
11 Central Java Surakarta City 250 233 93.20 245 98.00
12 Tegal City 250 224 89.60 234 93.60
13 DI Yogyakarta Yogyakarta City 250 173 69.20 173 69.20
14 East Java Pamekasan 250 54 21.60 54 21.60
15 Blitar City 250 51 20.40 51 20.40
16 Probolinggo City 250 120 48.00 120 48.00
17 Mojokerto City 250 56 22.40 57 22.80
18 Banten Tangerang 250 225 90.00 232 92.80
19 Cilegon City 250 187 74.80 189 75.60
20 Bali Buleleng 250 248 99.20 250 100.00
21 Denpasar City 250 247 98.80 248 99.20

19
 Behavioral Data Biological Data
District/
No Province Plan Actual # of Coverage Actual # of Coverage
Municipality
Respondents (%) Respondents (%)
22 NTB 250 (North
Mataram City 225 90.00 228 91.20
Lombok
23 North
Manado City 250 244 97.60 250 100.00
Sulawesi
250
24 Papua Mimika District (Puncak 180 72.20 189 75.60
District)
Total 6000 4596 76.6% 4660 77.7%

The above table shows that changes had to be made to data collection sites in three
Districts/Municipalities in three provinces, i.e. DKI Jakarta, West Nusa Tenggara (NTB) and
Papua. The Seribu Island District was replaced with North Jakarta City, North Lompok District
was replaced with Mataram City and Puncak District was replaced with Mimika District.
Substitution was made because:

a. According to key population size estimate, no MSM were identified in Seribu Island
District.
b. Following the earthquake that struck Lombok, it was not feasible to collect data in North
Lombok District.
c. The geographic condition of Puncak District created difficulty for data collection.

Among the 24 Districts/Municipalities, six Districts/Municipalities had a data collection coverage

that was below 50%. They were Simeuleu District (31.6%), East Aceh (26.4%), Pamekasan
District (21.6%), Probolinggo City (48.0%), Blitar City (20.4%) and Mojokerto City (22.4%).
These six Districts/Municipalities were therefore excluded from the aggregate data calculation as
the results were considered non-representative of the respective District/Municipality. In total
302 samples from the six Districts/Municipalities were excluded or around 6.2% of the total
collected samples.

3.1 Respondent Characteristics

From the planned 6000 MSM respondents, 4596 completed the interview. This section describes
the characteristics of MSM based on age, highest level of education, marital status, permanent
residence, current living arrangement, main occupation and health insurance coverage.

Table 3.2 Age Group and Educational Level of MSM

Age (%) Level of Education (%)
District/ Elementary Jr. High High
N Median Age 15-19 20-24 25-49 ≥50 Never went College/
Municipality School/ School/ School/
years years years years to school University
Equivalent Equivalent Equivalent
Simeulue# 79 25 27.8 21.5 50.6 0.0 0.0 10.1 24.1 54.4 11.4
East Aceh# 66 21 42.4 21.2 36.4 0.0 3.0 4.5 12.1 75.8 4.5

20
 Age (%) Level of Education (%)
District/ Elementary Jr. High High
N Median Age 15-19 20-24 25-49 ≥50 Never went College/
Municipality School/ School/ School/
years years years years to school University
Equivalent Equivalent Equivalent
Prabumulih City 250 26.5 26.8 18.4 53.2 1.6 0.0 10.4 20.0 64.8 4.8
Bandar
250 24 17.6 39.6 38.8 4.0 0.0 5.2 16.0 63.2 15.6
Lampung City
Batam City 250 28 12.4 24.4 60.8 2.4 0.4 7.6 15.6 61.6 14.8
South Jakarta
238 30 3.8 18.9 70.2 7.1 0.0 3.4 13.9 53.4 29.4
City
North Jakarta
246 28 8.1 25.6 61.0 5.3 0.4 5.7 15.4 61.8 16.7
City
Bogor 258 23 26.4 32.9 39.5 1.2 0.0 8.1 26.4 55.8 9.7
Bogor City 242 26 11.6 33.1 52.1 3.3 0.4 7.9 17.8 54.1 19.8
Depok City 250 25 8.4 37.2 52.8 1.6 0.4 2.4 6.4 72.0 18.8
Surakarta City 233 33 3.9 16.3 63.5 16.3 0.4 10.3 30.9 49.8 8.6
Tegal City 224 27 22.3 14.7 59.4 3.6 1.8 21.4 36.2 37.5 3.1
Yogyakarta City 173 24 14.4 44.3 39.7 1.7 0.0 1.2 4.0 35.8 59.0
Pamekasan# 54 23.5 29.6 25.9 44.4 0.0 0.0 1.9 0.0 59.3 38.9
Blitar City# 51 25 21.6 25.5 52.9 0.0 0.0 2.0 11.8 60.8 25.5
Probolinggo City 120 23 21.7 35.0 40.8 2.5 0.0 7.5 28.3 56.7 7.5
Mojokerto City# 56 30 8.9 25.0 62.5 3.6 0.0 5.4 7.1 75.0 12.5
Tangerang 225 24 20.0 32.9 45.3 1.8 0.0 10.2 22.7 63.1 4.0
Cilegon City 187 23 21.4 39.6 38.0 1.1 0.5 11.2 21.9 59.9 6.4
Buleleng 248 21 39.1 30.6 29.8 0.4 0.4 7.3 23.4 64.1 4.8
Denpasar City 247 28 3.6 24.3 71.7 0.4 0.8 4.0 10.1 61.5 23.5
Mataram City 225 23 28.9 27.1 42.2 1.8 1.3 3.1 16.4 64.4 14.7
Manado City 244 24 25.0 29.1 43.9 2.0 0.0 2.0 10.2 70.5 17.2
Mimika 180 24 18.9 37.2 43.9 0.0 0.0 0.6 2.8 88.9 7.8

Aggregate 4290 25 17.4 29.0 50.4 3.1 0.4 6.9 17.8 60.1 14.8
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The median age of respondents was 25 years. The oldest median age, at 33 years, was recorded
in Surakarta City, and the youngest was found in Buleleng District (21 years). A lot of the
respondents were relatively young, between 25 to 49 years (50.4%) and 17.4% were very young
(15-19 years of age). The highest proportion of young MSM (39.1%) was found in Buleleng
District. This is a group that is at high-risk of infection as they are young individuals with a high
level of curiosity and strong desire to experiment with risky sexual activities. In addition, this
group had limited exposure to educational and intervention programs.

The majority of respondents (74.9%) completed at least high school or even had a university
degree. In Yogyakarta City, the combined percentage of MSM who completed high school or
obtained higher education was 94.8%. Such high proportion of educated individuals implies that
they should have been more exposed to HIV/AIDS information. A cross-tabulation between level
of education and HIV/AIDS information showed that 83.0% and 92.7% of respondents who
completed high school and university respectively reported ever receiving information about
HIV/AIDS. This is a much higher exposure to information than respondents with lower level of
education.

21
 Another characteristic that was looked at was marital status and living arrangement of
respondents, which is summarized in Table 3.3. In this survey, being married was defined as being
legally married and were either living with the spourse or were having a long-distance marriage,
while widowers and divorced MSM were grouped under the ‘divorced‘ category. In terms of living
arrangement, the data only included respondents who had a permanent place to stay, whether it
was their own house, or a room or house that they rented.

Table 3.3 Marital Status and Living Arrangement of MSM

Marital Status (%) Current Living Arrangement (%)
District/ With
n n With With female
Municipality Unmarried Married Divorced Alone male/waria Other
friends/family sex partner
sex partner
Simeulue# 79 75.9 24.1 0.0 77 1.3 90.9 7.8 0.0 0.0
East Aceh# 66 86.4 12.1 1.5 63 4.8 88.9 6.3 0.0 0.0
Prabumulih City 250 68.0 25.6 6.4 245 8.2 73.5 18.0 0.0 0.4
Bandar 250 86.0 8.8 5.2 248 21.4 73.0 4.8 0.8 0.0
Lampung City
Batam City 250 86.0 11.2 2.8 249 34.5 52.6 8.0 4.8 0.0
South Jakarta 238 79.4 12.2 8.4 227 38.3 46.7 7.5 7.5 0.0
City
North Jakarta City 246 83.7 4.5 11.8 245 33.5 56.3 0.8 8.6 0.8
Bogor 258 88.8 7.8 3.5 253 23.3 63.6 5.9 2.0 5.1
Bogor City 242 83.5 10.7 5.8 238 22.3 68.9 5.5 2.9 0.4
Depok City 250 91.2 5.6 3.2 249 26.1 63.5 2.0 8.4 0.0
Surakarta City 233 56.7 35.2 8.2 220 29.1 41.4 27.3 2.3 0.0
Tegal City 224 62.5 30.8 6.7 209 5.7 69.9 23.4 0.0 1.0
Yogyakarta City 173 93.6 3.5 2.9 172 41.9 50.0 1.2 5.8 1.2
Pamekasan# 54 70.4 29.6 0.0 54 0.0 70.4 29.6 0.0 0.0
Blitar City# 51 92.2 7.8 0.0 51 9.8 82.4 5.9 0.0 2.0
Probolinggo City 120 67.5 25.0 7.5 118 9.3 89.0 0.8 0.8 0.0
Mojokerto City# 56 82.1 3.6 14.3 56 28.6 62.5 3.6 5.4 0.0
Tangerang 225 80.9 12.0 7.1 222 11.3 81.5 5.0 1.8 0.5
Cilegon City 187 86.6 10.2 3.2 181 19.3 71.3 6.6 1.7 1.1
Buleleng 248 82.3 16.9 0.8 235 0.9 96.2 3.0 0.0 0.0
Denpasar City 247 86.2 6.5 7.3 238 42.9 43.7 0.8 11.8 0.8
Mataram City 225 86.7 11.1 2.2 218 14.2 77.1 7.8 0.5 0.5

Manado City 244 94.3 4.1 1.6 240 19.6 70.8 0.4 8.8 0.4

Mimika 180 88.9 11.1 0.0 174 29.9 62.6 7.5 0.0 0.0

Aggregate 4290 81.9 13.1 5.0 4181 22.9 65.4 7.2 3.8 0.7

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

At the time of the interview, 81.9% of MSM respondents had never married, and 13.1% were
married. This indicates that as many as 560 wives of MSM were at risk of infection as a result of
their husbands’ (the respondents) sex behavior. The highest proportion of married MSM was
found in Surakarta City (35.2%), and the lowest was found in Yogyakarta City (3.5%).

22
 The majority of respondents (97.5%) or 4181 MSM had a permanent place to stay. About two-
thirds or 65.4% lived with their family or sibling, and around 23% lived alone. It is understood
that living alone provided more opportunity for MSM to engage in high-risk sex behavior due to
lack of control from family/friends. As detailed in Table 3.5, almost half of the time (47.7%), MSM
gathered at fellow MSM’s home/apartment/rental room.

Interestingly, only 3.8% of MSM respondents lived with their male or waria partner, and they
were mostly MSM in Denpasar City (11.8%). In general, these MSM were either single, or married
but did not live with their wives, or divorced. This situation shows that MSM are not yet able to
freely live with their male partner as they had to observe the norms in the society and avoid
creating problems with the surrounding community. As a result, MSM tended to stay within their
own circle of friends and were not willing to open up to others outside their community. This
finding is in line with the result of a qualitative study done by Hardisman (2018) that showed
MSM are not open about their life and sexual behavior to their “external” environment since
Nurdelia et al. (2016) also reported that the majority of people (91%) consider homosexuality as
a deviation from the norm.

The 2018-2019 IBBS also looked at respondents’ employment and insurance coverage, two
variables that demonstrate level of empowerment. This study did not specifically inquire about
the nature of respondent’s job and simply constructed several categories based on whether or
not respondents received a fixed and steady salary/honoraria per month. Grouping was also done
based on ownership of health insurance, and the type of insurance (public, private or both).
Another characteristic presented was circumcision to obtain information about the circumcision
status among MSM.

Table 3.4 Employment, Health Insurance Coverage and Circumcision Status of MSM
Employment of MSM (%) Health Insurance (%)
Circumcision
District / Job with Job with Free- Government
n Government Private No Status
Municipality Unemployed steady non-steady lance and private
insurance insurance insurance (%)
income income Work insurance
Simeulue# 79 22.8 6.3 12.7 58.2 88.6 1.3 6.3 3.8 98.7
East Aceh# 66 40.9 25.8 19.7 13.6 84.8 0.0 4.5 10.6 100.0
Prabumulih City 250 37.6 20.0 27.2 15.2 63.6 0.4 3.6 32.4 100.0
Bandar
250 24.8 38.0 17.6 19.6 71.2 0.8 2.4 25.6 99.2
Lampung City
Batam City 250 11.6 56.8 6.4 25.2 68.4 1.2 1.2 29.2 89.6
South Jakarta
238 12.6 48.3 26.5 12.6 63.0 2.1 5.0 29.8 87.8
City
North Jakarta
246 17.5 39.0 17.1 26.4 54.1 4.1 0.4 41.5 95.5
City
Bogor 258 28.3 35.7 26.4 9.7 47.3 0.8 19.0 32.9 96.9
Bogor City 242 24.8 39.3 21.1 14.9 71.1 1.7 0.8 26.4 97.1
Depok City 250 26.8 45.6 19.6 8.0 66.4 3.2 2.0 28.4 98.0
Surakarta City 233 9.0 30.9 20.6 39.5 70.4 2.6 2.6 24.5 98.3
Tegal City 224 10.7 27.2 17.0 45.1 49.1 4.5 1.3 45.1 100.0

23
 Employment of MSM (%) Health Insurance (%)
Circumcision
District / Job with Job with Free- Government
n Government Private No Status
Municipality Unemployed steady non-steady lance and private
insurance insurance insurance (%)
income income Work insurance
Yogyakarta City 173 38.2 34.7 17.9 9.2 63.6 7.5 6.9 22.0 91.9
Pamekasan# 54 53.7 14.8 9.3 22.2 22.2 0.0 1.9 75.9 100.0
Blitar City# 51 23.5 52.9 17.6 5.9 58.8 0.0 2.0 39.2 100.0
Probolinggo
120 27.5 8.3 57.5 6.7 61.7 0.0 0.8 37.5 93.3
City
Mojokerto City# 56 3.6 55.4 30.4 10.7 64.3 5.4 3.6 26.8 100.0
Tangerang 225 40.0 30.7 16.9 12.4 37.8 6.7 2.7 52.9 97.3
Cilegon City 187 49.2 28.3 5.3 17.1 46.0 2.1 2.1 49.7 95.7
Buleleng 248 46.0 14.5 6.0 33.5 55.6 2.8 2.0 39.5 25.8
Denpasar City 247 6.1 57.9 21.5 14.6 55.1 2.0 4.5 38.5 76.1
Mataram City 225 46.2 31.6 12.0 10.2 56.4 1.3 0.4 41.8 97.3
Manado City 244 43.4 25.4 4.1 27.0 63.1 6.6 2.0 28.3 38.1
Mimika 180 30.6 60.0 7.8 1.7 72.8 1.1 0.6 25.6 68.9

Aggregate 4290 27.5 36 17.6 19.0 59.8 2.7 3.3 34.2 86.4
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Out of all the respondents, about a quarter were unemployed, and they were mostly MSM who
were still at school or university (80%). This lack of income influenced their access to health
insurance, as well as access to health care. Only 52.9% of unemployed MSM had health insurance
coverage, lower than the percentage among the employed MSM (62%-79%).

Overall, 65.8% of MSM had health insurance, either through the government (BPJS), or private
insurance, or both. In provinces that have declared success in achieving Universal Health
Coverage (UHC) like DKI Jakarta, coverage of government insurance (BPJS) actually only ranged
from 54.1%-63.0%. In fact, 41.8% of MSM in South Jakarta reported not having any type of health
insurance. As mentioned by Mc. Kirnan, et al. (2013), insurance ownership is critical to improve
one’s attitude toward health care (trust on the health care system, a chance to reveal one’s status
as an MSM to a health provider), improve general health behavior (smoking, HIV test, drug abuse),
and improve other variables that relate to sexual risk (low self-efficacy for safe sex, consistent use
of drug during sex and risk of HIV transmission).

Circumcision status is considered an important variable since circumcicion is one factor that
prevents HIV transmission among MSM. As a meta-analysis by Yuan, et al. (2019) reported, the
odds of HIV infection among circumcised MSM is reduced by 23%. The 2018-2019 IBBS recorded
that 86.4% of MSM were circumcised, and in some Districts/Municipalities the percentage was
even 100%. This was because circumcision is mandatory for muslims. In areas where the majority
of population was not muslim, circumcision rate was low, like in Buleleng District and Manado
City, where the percentage of circumcised respondents was only 25.8% and 38.1% respectively.

Table 3.5 below presents information about places MSM typically gather. Each respondent may
respond with one or more answers.

24
 Table 3.5 Gathering Places of MSM
MSM’s Gathering Places (%)
Bar/ Disco/ Massage Home/ Terminal / Internet/
District / Park /
Mall/ Pub/Café/ Parlor / Rental Hotel / Station / Online
Municipality n Town Campus Other
Minimarket Restaurant/ Salon / Room / Motel Sea port/ Game
Square
Movie theater Gym Apartment Airport Cafe

Simeulue# 79 0.0 0.0 0.0 1.3 1.3 0.0 3.8 0.0 0.0 19.0
East Aceh# 66 3.0 13.6 10.6 42.4 21.2 3.0 4.5 3.0 1.5 6.1
Prabumulih
250 23.2 2.8 34.4 38.4 79.2 6.0 8.4 21.2 1.2 0.0
City
Bandar
250 16.8 29.2 6.8 44.4 20.8 12.0 1.6 0.8 2.8 9.2
Lampung City
Batam City 250 70.8 64.0 11.2 88.8 50.4 17.2 3.6 6.8 1.2 3.2
South Jakarta
238 65.1 48.3 15.5 42.4 22.3 14.3 7.1 7.6 4.6 4.2
City
North Jakarta
246 54.9 44.3 13.0 47.6 42.7 16.3 4.5 2.4 6.1 5.7
City
Bogor 258 57.4 49.6 22.5 73.3 56.2 5.8 10.1 5.0 1.6 2.3
Bogor City 242 37.2 6.6 2.1 38.8 33.9 0.8 1.2 0.0 0.0 7.4
Depok City 250 53.6 34.8 5.2 56.8 13.6 4.4 0.4 2.8 3.2 0.8
Surakarta City 233 32.2 10.3 24.9 26.6 56.2 32.6 25.3 5.2 9.0 0.9
Tegal City 224 5.4 6.3 3.6 24.1 60.7 1.3 4.5 0.0 0.0 4.0
Yogyakarta
173 37.6 50.9 7.5 65.9 22.5 13.9 6.4 6.4 17.9 9.2
City
Pamekasan# 54 0.0 0.0 0.0 14.8 24.1 0.0 0.0 0.0 0.0 9.3
Blitar City# 51 13.7 47.1 7.8 68.6 19.6 17.6 0.0 0.0 2.0 15.7
Probolinggo
120 22.5 32.5 24.2 50.0 36.7 5.8 2.5 2.5 0.0 0.0
City
Mojokerto
56 35.7 57.1 10.7 25.0 42.9 7.1 0.0 0.0 1.8 8.9
City#
Tangerang 225 24.0 4.0 25.8 49.8 35.6 0.4 0.9 0.9 0.0 5.8
Cilegon City 187 9.1 11.2 3.7 37.4 47.6 5.9 1.6 1.1 0.5 0.5
Buleleng 248 73.4 9.7 6.9 21.8 36.3 4.8 0.4 4.0 1.6 0.0
Denpasar City 247 26.7 53.8 8.5 58.3 21.9 2.8 3.2 0.8 0.8 10.9
Mataram City 225 23.1 7.1 4.9 33.3 76.0 3.6 0.9 3.1 0.9 5.8
Manado City 244 47.1 13.9 8.2 54.5 7.8 11.5 1.2 1.2 1.6 2.9
Mimika 180 15.6 50.6 19.4 52.8 6.1 6.1 0.0 0.0 1.1 0.0

Aggregate 4290 38 27.7 12.9 47.7 38.7 8.8 4.5 3.9 2.8 3.9
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Almost half (47.7%) of respondents cited their own personal place like home/rental
room/apartment as places for them to gather with fellow MSM. In Batam City, almost all of the
respondents (88.8%) mentioned that they hung out at a ‘closed’ place. This indicates that MSM
prefer private venues to public places. There was however about one-third of respondents who
liked to gather in public facilities like a park or town square (38.7%) and the mall/minimarket
(38%). For example, 79.2% of MSM in Prabumulih City liked to gather at a park/town square, and
73.4% of MSM in Buleleng City chose the mall/minimarket. Intervention programs can therefore
take advantage of this situation and perform health promotion with the appropriate media at
those venues.

25
 3.2 Virtual Network
This section describes respondents’ access to electronic media, and their exposure to information
and communication materials about HIV/AIDS prevention and intervention. Some of the
questions were only asked to respondents who accessed internet, but to provide a picture of all
the MSM respondents, adjustment was made by multiplying the result with the percentage of
internet access.

Table 3.6 MSM’s Internet Access, Information Search, Online Communication and Exposure to Social Media
Member of Access Social Media Sites that are Used Most Often* (%)
Visit
mailing internet to Communicate
Access Waria-
District / list/ find HIV- online about
n Internet related Do not do
Municipality WA related HIV* Gay-related
(%) websites* social FB^ Twitter IG^ Other
Group* information* (%) application
(%) media
(%) (%)
Simeulue# 79 65.8 0.0 0.0 0.0 1.3 16.5 49.4 0.0 0.0 0.0 0.0
East Aceh# 66 89.4 30.3 24.2 6.1 4.5 1.5 50.0 4.5 25.8 4.5 1.5
Prabumulih
250 81.2 36.8 36.0 5.2 2.0 10.0 54.4 2.4 14.0 0.0 0.4
City
Bandar
250 96.4 40.8 22.0 21.2 12.8 0.8 56.8 2.0 29.2 6.8 0.8
Lampung City
Batam City 250 98.0 65.6 7.6 16.4 10.4 0.0 65.2 6.8 17.2 8.0 0.8
South Jakarta
238 84.0 63.9 21.4 19.7 10.5 2.5 28.2 5.0 27.7 18.9 1.7
City
North Jakarta
246 90.7 41.1 24.8 36.2 29.7 7.7 45.9 4.5 16.3 13.8 2.4
City
Bogor 258 81.0 52.3 48.4 26.4 22.9 19.8 30.6 4.7 14.7 10.1 1.2
Bogor City 242 95.5 50.8 28.5 32.2 22.3 2.9 53.7 1.2 28.5 7.9 1.2
Depok City 250 96.4 50.4 33.2 19.2 13.6 9.6 31.2 0.8 20.8 32.0 2.0
Surakarta City 233 77.7 53.6 30.9 34.8 31.3 3.4 44.6 4.3 2.6 22.3 0.4
Tegal City 224 75.9 30.8 7.1 17.0 8.9 0.9 57.1 0.9 7.1 4.0 5.8
Yogyakarta
173 99.4 50.3 43.0 55.5 30.6 1.2 22.5 10.4 47.4 9.8 8.1
City
Pamekasan# 54 88.9 0.0 0.0 5.6 1.9 3.7 63.0 0.0 20.4 0.0 1.9
Blitar City# 51 98.0 60.8 33.3 51.0 15.7 0.0 45.1 7.8 41.2 3.9 0.0
Probolinggo
120 68.3 20.0 9.2 29.2 26.7 0.0 61.7 3.3 3.3 0.0 0.0
City
Mojokerto City
#
56 96.4 64.3 55.4 44.6 17.9 0.0 73.2 1.8 14.3 1.8 5.4

Tangerang 225 98.7 33.3 11.6 20.9 14.7 5.3 67.1 6.7 7.6 7.6 4.4
Cilegon City 187 82.4 45.5 9.1 15.5 12.3 9.6 44.4 2.7 6.4 19.3 0.0
Buleleng 248 99.2 27.4 30.2 48.8 41.5 0.8 84.3 4.4 9.7 0.0 0.0
Denpasar City 247 99.2 59.1 23.9 44.5 24.7 0.4 38.9 3.2 40.5 14.6 1.6
Mataram City 225 78.2 20.0 20.4 10.2 6.7 2.2 66.7 0.4 5.3 1.8 1.8
Manado City 244 98.4 54.5 40.2 19.3 16.4 0.0 72.1 1.2 5.7 16.0 2.9
Mimika 180 100.0 8.3 0.6 6.7 1.7 0.6 54.4 1.1 27.8 0.0 16.1

Aggregate 4290 90 43,6 24,5 25,1 17,8 4,3 51,7 3,4 17,6 10,5 2,5
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Presented results
have been multiplied with the proportion of respondents who access internet and therefore illustrate the whole respondents;
^IG=Instagram, FB=Facebook

26
 Most respondents (90%) accessed internet at varying frequency. About 43.6% also visited Waria-
related websites and some (24.5%) were members of a mailing list or WhatsApp group. Only
25.1% utilized the internet to search for information on HIV/AIDS transmission and prevention,
and only 17.8% communicated online to discuss or find information about HIV. This result shows
that online information search and communication about HIV among the MSM was still quite low,
but could potentially be increased considering that almost all respondents are able to access the
internet.

Studies have shown that internet is a highly effective media to promote information about sexual
health and behavior (Bailey, 2010). For the MSM community, specifically young MSM, internet
al.so provided them with an opportunity to learn about sexuality, to share stories and receive
support from other internet users (Young, 2011). The internet has become a highly popular
communication method for MSM as it allows them to maintain their identity private (preserve
confidentiality) much better than direct face-to-face meeting (Blas, 2007; Hughes, 2009).
Internet also enabled MSM to easily find sex partners, which is likely to impact sexual behavior
and disease transmission.

As much as 95.7% of respondents used social media, with Facebook being the most common
(51.7%) followed by Instagram (17.6%). This means that social media is another opportunity that
HIV prevention programs can use to promote safe sex behavior, HIV/AIDS prevention and other
information. This would enable MSM, in addition to the general population, to be exposed to the
information.

3.3 Knowledge about HIV, Its Risk and Prevention

3.3.1 Knowledge about HIV

Respondents’ level of knowledge was obtained by first finding out about HIV/AIDS information
that respondents had received before the interview. Afterwards, the respondent was asked
whether or not an individual who looks healthy can be infected with HIV. Then two questions on
HIV prevention were asked, followed with two questions about misconceptions in HIV
transmission. Each of these five questions was weighted equally and correct response to all these
five questions would be defined as having comprehensive knowledge about HIV.

Table 3.7 MSM’s Information and Knowledge about HIV

Knowledge about HIV
Had received Prevention of HIV Transmission of HIV
Healthy-
information Reduce risk HIV IS NOT
about HIV looking Reduce risk of HIV IS NOT
District/Municipality n of HIV transmitted Comprehensive
before the individual HIV infection transmitted
infection by through Knowledge*
interview can be HIV- by using by sharing
being faithful mosquito/ (%)
(%) infected condom food
to partner insect bite
(%) (%) (%)
(%) (%)
Simeulue# 79 68.4 31.6 43.0 46.8 30.4 35.4 3.8
Aceh Timur# 66 60.6 30.3 57.6 51.5 53.0 60.6 13.6

27
 Knowledge about HIV
Had received Prevention of HIV Transmission of HIV
Healthy-
information Reduce risk HIV IS NOT
about HIV looking Reduce risk of HIV IS NOT
District/Municipality n of HIV transmitted Comprehensive
before the individual HIV infection transmitted
infection by through Knowledge*
interview can be HIV- by using by sharing
being faithful mosquito/ (%)
(%) infected condom food
to partner insect bite
(%) (%) (%)
(%) (%)
Prabumulih City 250 65.2 38.0 58.0 51.2 56.4 42.8 26.0
Bandar Lampung City 250 74.0 70.0 86.8 86.4 70.0 65.6 47.6
Batam City 250 94.4 88.8 99.2 98.8 73.6 81.6 68.0
South Jakarta City 238 76.1 54.6 84.9 79.4 79.8 79.4 37.8
North Jakarta City 246 64.2 68.7 71.5 74.0 64.6 67.5 39.0
Bogor 258 87.2 79.1 89.5 84.9 92.6 90.7 70.5
Bogor City 242 90.5 63.2 90.5 83.1 71.5 83.5 38.8
Depok City 250 88.0 62.0 85.6 82.4 83.2 81.6 41.6
Surakarta City 233 71.2 63.1 69.1 70.8 62.2 60.9 48.1
Tegal City 224 61.6 72.8 82.1 78.6 44.2 45.1 26.8
Yogyakarta City 173 96.5 91.9 90.2 87.3 78.6 89.0 63.6
Pamekasan# 54 27.8 13.0 35.2 35.2 18.5 0.0 3.7
Blitar City# 51 90.2 88.2 78.4 76.5 74.5 66.7 49.0
Probolinggo City 120 82.5 46.7 69.2 76.7 30.8 32.5 7.5
Mojokerto City# 56 96.4 80.4 91.1 82.1 71.4 83.9 51.8
Tangerang 225 83.1 75.6 83.1 70.2 62.7 50.2 46.2
Cilegon City 187 57.2 59.4 87.2 80.7 67.4 59.4 30.5
Buleleng 248 86.3 45.6 78.2 78.6 68.1 49.2 26.2
Denpasar City 247 93.5 87.9 87.9 82.2 67.2 81.4 47.0
Mataram City 225 67.1 52.9 81.8 78.2 50.7 50.2 30.2
Manado City 244 81.1 46.3 73.4 66.0 69.7 72.1 25.8
Mimika 180 84.4 46.1 76.7 83.3 70.6 63.3 26.1

Aggregate 4290 79.2 64.2 81.5 78.5 67.6 66.6 40.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples ; *Comprehensive
knowledge is percentage of respondents with correct answers for the variable: healthy-looking individual can be HIV-infected, reduce
risk of HIV infection by using condom, reduce risk of HIV infection by being faithful to partner, HIV is not transmitted through mosquito
bite and HIV is not transmitted by sharing food.

The above table shows that there was still around a fifth of MSM respondents (20.8%) who had
never received information about HIV/AIDS before the interview. It was therefore assumed that
respondents who fall in this category had never been exposed to information about HIV
prevention. Cross-tabulation between educational level and exposure to HIV information showed
that 35.0% to 45.2% of less-educated respondents did not receive any HIV information. In
contrast, among respondents with high school diploma and university degree, only 17% and 7.4%
of them respectively were not exposed to HIV information.

Respondents’ knowledge about HIV was assessed from questions about whether or not a healthy-
looking individual can be infected with HIV, also questions about HIV prevention and
misconceptions in HIV transmission. Overall, only 64.2% respondents correctly stated that a
healthy-looking individual can be HIV-infected. In some Districts/Municipalities, less than 40%
respondents had that correct information.

28
Knowledge about condom as a prevention device was correctly mentioned by around 81.5%
respondents. This was slightly higher than the proportion of respondents (78.5%) who cited
faithfulness to one’s partner as a way to prevent HIV infection. Overall this meant that a large
proportion of respondents already had correct knowledge about HIV prevention. Unfortunately,
in some Districts/Municipalities, the percentage of correct answers to these two questions was
still below 75% (Prabumulih City, North Jakarta City, Surakarta City and Manado City).

About two-thirds of respondents (67.6%) answered correctly to questions regarding mosquito

bite and HIV transmission, and a similar percentage (66.6%) also answered correctly when asked
whether HIV can be transmitted through eating together with an HIV-positive individual. This
means that one-third of respondents still held on to those misconceptions, and in some
Districts/Municipalities, i.e. Prabumulih City, Tegal City and Probolinggo City, the percentage of
respondents with correct knowledge was less than 50%.

Those five variables about knowledge were then combined into one composite variable of
comprehensive knowledge. The result showed that 40% of respondents had comprehensive
knowledge about HIV, which was very low. The remaining 60% still had inaccurate information
about HIV. Only three Districts/Municipalities had respondents with comprehensive knowledge
above 50%. They were Batam City (68.0%), Bogor City (70.5%) and Yogyakarta City (63.6%).

3.3.2 Risk Perception for HIV and Protective Behavior

This next variable explored respondents’ perception about their risk of HIV/AIDS transmission,
and efforts that they have made to protect themselves from infection. Three types of protective
behavior were asked, namely consistent use of condom, being faithful to one’s sex partner, and
not sharing injection needles.

Table 3.8 Risk Perception and Protective Behavior of MSM

Protective Behavior of Respondents
Perception of Risk for Do not share
District/Municipality n Always use Be faithful to sex
HIV Infection (%) non-sterile
condom (%) partner (%)
needles (%)
Simeulue# 79 30.4 20.3 11.4 24.1
East Aceh# 66 28.8 71.2 50.0 34.8
Prabumulih City 250 21.6 76.8 66.4 60.0
Bandar Lampung City 250 74.2 86.4 64.8 37.6
Batam City 250 79.3 95.2 97.2 95.6
South Jakarta City 238 59.8 89.5 77.7 66.0
North Jakarta City 246 64.9 78.9 65.4 32.1
Bogor 258 86.5 91.5 74.8 57.4
Bogor City 242 67.4 90.5 71.5 62.4
Depok City 250 75.3 90.0 77.2 40.4
Surakarta City 233 83.1 86.7 73.8 4.7
Tegal City 224 63.3 89.7 58.0 39.7
Yogyakarta City 173 67.7 85.5 84.4 67.6

29
 Protective Behavior of Respondents
Perception of Risk for Do not share
District/Municipality n Always use Be faithful to sex
HIV Infection (%) non-sterile
condom (%) partner (%)
needles (%)
Pamekasan# 54 1.6 51.9 44.4 57.4
Blitar City# 51 64.9 94.1 94.1 56.9
Probolinggo City 120 45.9 93.3 87.5 47.5
Mojokerto City# 56 47.9 94.6 87.5 94.6
Tangerang 225 64.2 87.1 53.3 29.8
Cilegon City 187 70.4 80.7 32.6 9.6
Buleleng 248 32.4 92.7 31.5 12.1
Denpasar City 247 48.2 93.9 80.6 68.4
Mataram City 225 48.3 72.0 56.4 29.8
Manado City 244 57.7 81.6 59.4 34.4
Mimika 180 13.8 69.4 83.3 33.9

Aggregate 4290 64.1 86.0 67.8 46.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The above table shows that overall, 64.1% of MSM respondents perceived themselves as being at
risk of HIV infection. The highest risk perception (86.5%) was found among respondents in Bogor
District. Risk perception is critical for promoting safe sex behavior. Most respondents mentioned
that the reason they felt at risk was because they had engaged in unprotected sex in the past
(93%). High risk perception also increased respondent’s awareness about HIV/AIDS prevention
and testing. This is in line with the result of a study by Marcus, Gassowski & Drewes (2016) that
reported how MSM with high risk perception underwent more HIV testing than those with low
risk perception.

For prevention, condom was the most common method (86.0%), while the least common
preventive effort was avoiding injection needle sharing (46.4%). In this survey, 2.1% of MSM (88
respondents) were also injecting drug users.

3.4 Condom and Sexual Behavior

3.4.1 Access to condom

Condom is important in HIV/AIDS and STI prevention and intervention program. This survey
found that 2.3% of MSM respondents did not know about condom (when condom was shown to
them), and follow-on questions therefore were asked only to respondents who knew about
condom, totaling to 4176 MSM. The next table presented various ways respondents used to obtain
condom within the last month, places that sell condom and places that provide free condom.

Table 3.9 Ways to Obtain Condom, Places that Sell Condom and Places that Provide Free Condom

30
 Ways to obtain condom in the last month* Places that sell condom ** Places that provide free condom***
(%) (%) (%)
District/
Municipality Did not Received Bought and
Bought Pharmacy / Health Outreach
n have free received n Shops n Friends NGO
condom Drug Store Facility worker
condom condom free condom
Simeulue# 27 92.6 7.4 0.0 0.0 2 0.0 100.0 0

East Aceh# 61 45.9 39.3 4.9 9.8 30 16.7 76.7 9 11.1 55.6 11.1 11.1
Prabumulih
242 35.1 28.9 9.9 26.0 133 35.3 64.7 87 1.1 10.3 58.6 28.7
City
Bandar
246 17.5 39.0 31.3 12.2 126 74.6 24.6 107 7.5 27.1 42.1 21.5
Lampung City
Batam City 250 17.2 56.0 18.0 8.8 162 71.0 25.9 67 6.0 31.3 47.8 10.4
South Jakarta
227 10.1 46.7 21.1 22.0 156 57.1 42.3 98 19.4 45.9 27.6 3.1
City
North Jakarta
239 18.0 43.1 19.7 19.2 149 88.6 9.4 93 19.4 47.3 30.1 1.1
City
Bogor 247 11.7 33.6 18.2 36.4 173 59.0 39.3 135 17.8 8.1 53.3 15.6

Bogor City 233 29.6 18.0 42.5 9.9 65 81.5 16.9 122 6.6 15.6 63.1 12.3

Depok City 249 24.5 31.3 34.5 9.6 102 52.0 47.1 110 7.3 19.1 65.5 5.5

Surakarta City 225 15.1 16.9 32.0 36.0 119 9.2 90.8 153 0.7 2.0 56.2 36.6

Tegal City 223 32.7 42.2 18.8 6.3 108 32.4 65.7 56 5.4 55.4 19.6 14.3
Yogyakarta
173 29.5 26.0 33.5 11.0 64 59.4 34.4 77 1.3 11.7 72.7 3.9
City
Pamekasan# 51 74.5 19.6 3.9 2.0 11 27.3 72.7 3 33.3 66.7 0.0 0.0

Blitar City# 51 41.2 39.2 13.7 5.9 23 56.5 43.5 10 30.0 60.0 0.0 0.0
Probolinggo
109 67.0 11.0 10.1 11.9 25 52.0 48.0 24 50.0 12.5 37.5 0.0
City
Mojokerto
56 14.3 26.8 39.3 19.6 26 61.5 38.5 33 39.4 39.4 9.1 12.1
City#
Tangerang 222 30.2 18.0 39.2 12.6 68 60.3 36.8 115 2.6 11.3 20.9 62.6

Cilegon City 179 12.8 45.3 29.6 12.3 103 68.9 29.1 75 1.3 21.3 12.0 64.0

Buleleng 238 21.8 23.1 40.3 14.7 90 33.3 63.3 131 7.6 58.0 6.1 25.2

Denpasar City 243 18.1 19.3 47.3 15.2 84 75.0 25.0 152 30.9 27.0 27.6 13.8

Mataram City 221 29.0 39.8 19.0 12.2 115 64.3 34.8 69 2.9 26.1 10.1 44.9

Manado City 234 20.5 28.2 44.0 7.3 83 62.7 36.1 120 32.5 27.5 15.8 21.7

Mimika 176 48.9 38.6 11.4 1.1 70 5.7 94.3 22 40.9 59.1 0.0 0.0

Aggregate 4176 24.2 32.4 28.0 15.4 1995 56.0 42.5 1813 12.0 25.1 37.2 22.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who knew about condom; **Among respondents who bought condom, the total was not 100% as the percentage of
answers for several categories: bar/hotel/motel, pimp, was very low or zero. These answer categories were therefore excluded;
***Among respondents who received free condom, the total was not 100% as the percentage of answers for several categories: client,
pimp, condom outlet, was very low or zero. These answer categories were therefore excluded.

At the time of the interview, almost a quarter of respondents mentioned that they did not have
condom in the last month (24.2%). In some Districts/Municipalities, the percentage was even
more than half, for example 67.0% in Probolinggo City. This is an issue that requires attention
because any sexual activity in that last month would have been done without condom, resulting
in an even higher risk for HIV and STI transmission. One interesting finding was that the
proportion of MSM who bought condom was higher than the proportion who received free
condom (32.4% vs. 28.0%), demonstrating affordability on the part of respondents to buy
condom, awareness to prepare condom, and less reliance on free condom.

31
Among MSM who bought condom, 56% of them did so at a local shop, while the rest bought
condom from a pharmacy/drug store. This shows that condoms are sold freely and are easily
available.

Among respondents who received free condom, 37.2% received them from NGOs, and 24.2%
received them from friends. Communities who had links with NGOs and peer groups generally
had quite a broad network that enabled them to reach out to MSM.

3.4.1.1 Condom Brand, Condom Breakage and Use of Lubricant

Table 3.10 below presents information about the various condom brands that MSM used,
experiences with condom breakage and use of lubricant during sex. Questions on condom brand
and use of lubricant were asked only to respondents who knew about condom, while the question
on condom breakage was asked to respondents who had condom in the last month.

Table 3.10 Condom Brand, Condom Breakage and Use of Lubricant

Experience with Use of water/gel-

Brand of Condom* (%)
District/ Municipality Condom Breakage** based lubricant*
n Sutra Fiesta Other n % n %
Simeulue# 27 0.0 0.0 74.1 2 50.0 27 3.7
Aceh Timur# 61 6.6 6.6 19.7 28 27.3 61 59.0
Prabumulih City 242 28.1 28.1 20.2 141 5.1 242 76.4
Bandar Lampung City 246 9.3 9.3 15.4 187 7.4 246 75.2
Batam City 250 10.0 10.0 19.6 204 7.7 250 82.0
South Jakarta City 227 11.0 11.0 25.6 194 19.1 227 74.0
North Jakarta City 239 8.8 8.8 23.4 188 16.3 239 67.8
Bogor 247 14.2 14.2 27.5 200 43.1 247 89.9
Bogor City 233 6.0 6.0 25.8 154 8.5 233 76.4
Depok City 249 17.3 17.3 18.1 185 16.5 249 89.6
Surakarta City 225 6.2 6.2 8.9 163 15.2 225 75.1
Tegal City 223 9.4 9.4 13.5 149 13.3 223 36.8
Yogyakarta City 173 15.6 15.6 19.7 111 6.6 173 78.0
Pamekasan# 51 5.9 5.9 68.6 11 0.0 51 7.8
Blitar City# 51 9.8 9.8 21.6 27 13.3 51 76.5
Probolinggo City 109 59.6 59.6 11.0 23 11.1 109 45.0
Mojokerto City# 56 5.4 5.4 14.3 46 12.5 56 85.7
Tangerang 222 8.6 8.6 6.8 148 5.8 222 82.9
Cilegon City 179 6.1 6.1 8.4 144 6.4 179 63.7
Buleleng 238 10.9 10.9 4.2 136 10.2 238 39.5
Denpasar City 543 1.7 1.7 61.5 194 7.0 543 85.2
Mataram City 221 10.9 10.9 20.8 152 15.3 221 57.5
Manado City 234 6.8 6.8 10.7 174 11.3 234 70.1
Mimika 176 5.7 5.7 14.8 80 17.8 176 47.2

Aggregate 4176 71.6 11.9 7.5 2927 14.5 4176 70.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who knew about condom; **Among respondents who had condom

32
 Data on condom brand is quite important to obtain information about any specific brand that the
MSM group preferred. The above table shows that Sutra was the most common condom brand
MSM used and was mentioned by almost 72% respondents. This indicates that respondents felt
comfortable using this brand. It implies that for programs that provide free condoms, choosing a
brand that is popular among MSM would make the product better accepted by the target
population.

Around 14.5% respondents also reported experiencing condom breakage during sex. As a result,
the individuals involved would not be protected against HIV and STI infection. Several studies
documented a link between condom breakage and use of oil-based lubricant (p-value 0.0009)
(HernándezRomieu AC, Siegler AJ, Sullivan PS, et al., 2014). However, in this IBBS, use of oil-based
lubricant is unknown.

3.4.2 Sexual Behavior and Condom Use

Characteristically, MSM couples are slightly different from heterosexual couples in that MSM
couples usually had a very low level of commitment to stay with one steady partner. Many MSM
couples had several concurrent relationships, resulting in a variety of sexual partnerships as
detailed in the following tables.

Sex partners of MSM could either be male (steady, and casual partner, buying and selling sex),
waria, female (steady, and casual partner, buying and selling sex), or a number of partners during
sex parties. Condom use is one way to prevent transmission of HIV-AIDS, and respondents were
therefore asked about their condom use behavior during their last sex encounter and also their
consistency in using condom in the last month with each type of sex partner.

3.4.2.1 Age at First Sexual Intercourse

The age respondents first had sex (either vaginal or anal) is an important variable to identify risky
sexual behavior. The table below lists the numerical and categorical age respondents had sexual
intercourse for the first time.

Table 3.11 Age of MSM’s First Sexual Intercourse

Age at first vaginal intercourse Age at first anal intercourse
(%) (%)
District/Municipality n Median Median
≤ 14 15-17 18-24 ≥ 25 Do not ≤ 14 15-17 18-24 ≥ 25 Do not
years years years years remember years years years years remember
Simeulue# 79 8 68.4 2.5 10.1 5.1 13.9 8 86.1 0.0 3.8 2.5 7.6
East Aceh# 66 8 39.4 6.1 12.1 1.5 40.9 8 28.8 6.1 10.6 3.0 51.5

Prabumulih City 159 19 15.1 6.9 25.2 10.7 42.1 18 6.0 19.8 21.0 5.2 48.0

Bandar
158 18 3.2 33.5 55.7 3.2 4.4 19 3.7 25.9 51.0 9.9 9.5
Lampung City
Batam City 137 19 8.0 21.2 45.3 25.5 0.0 20 4.4 21.7 55.4 17.3 1.2
South Jakarta
193 18 26.4 14.5 33.7 14.0 11.4 20 8.2 17.7 45.5 17.7 10.8
City
North Jakarta
226 18 30.5 17.3 41.2 8.8 2.2 20 9.4 20.4 52.7 17.1 0.4
City

33
 Age at first vaginal intercourse Age at first anal intercourse
(%) (%)
District/Municipality n Median Median
≤ 14 15-17 18-24 ≥ 25 Do not ≤ 14 15-17 18-24 ≥ 25 Do not
years years years years remember years years years years remember
Bogor 101 17 7.9 28.7 22.8 2.0 38.6 16 13.0 57.3 17.0 1.6 11.1
Bogor City 184 17 29.9 24.5 36.4 8.2 1.1 19 9.3 22.9 48.9 14.5 4.4
Depok City 89 20 2.2 9.0 44.9 13.5 30.3 19 2.9 13.8 47.3 9.2 26.8

Surakarta City 159 20 1.3 11.9 39.0 19.5 28.3 21 2.2 6.7 39.5 21.5 30.0

Tegal City 176 18 4.0 37.5 40.3 11.9 6.3 20 4.8 25.0 34.1 25.0 11.1

Yogyakarta City 80 18 23.8 16.3 36.3 10.0 13.8 19 7.6 16.9 60.5 9.9 5.2

Pamekasan# 17 27 0.0 0.0 11.8 17.6 70.6 20 0.0 9.7 41.9 3.2 45.2
Blitar City# 18 17 22.2 33.3 16.7 22.2 5.6 20 6.0 24.0 52.0 16.0 2.0

Probolinggo City 91 16 3.3 56.0 36.3 1.1 3.3 16 3.8 61.5 26.9 2.9 4.8

Mojokerto City# 17 21 0.0 0.0 76.5 23.5 0.0 19 2.0 33.3 39.2 23.5 2.0

Tangerang 136 18 5.1 30.9 32.4 10.3 21.3 18 4.6 26.4 32.4 7.9 28.7
Cilegon City 138 18 3.6 34.8 39.9 6.5 15.2 18.5 3.4 28.5 44.7 8.4 15.1
Buleleng 242 17 1.7 58.3 38.8 0.4 0.8 18 0.4 47.7 50.6 0.8 0.4

Denpasar City 138 19 3.6 21.7 52.9 18.8 2.9 20 9.5 13.6 56.2 18.6 2.1

Mataram City 191 18 7.3 37.2 49.7 4.2 1.6 18 5.4 32.6 49.1 8.0 4.9

Manado City 151 18 4.6 33.8 35.1 4.6 21.9 18 7.6 26.7 43.8 7.1 14.8
Mimika 155 18 6.5 38.7 38.1 10.3 6.5 18 6.6 27.0 40.1 1.3 25.0
Aggregate 4290 18 10.61 28.72 39.46 9.47 11.74 18 6.1 26.1 43.3 11.1 13.5
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The above data shows that the median age of first sexual intercourse, either vaginal or anal, was
18 years. There was also 10.6% and 6.1% of MSM who were younger than 14 when they first had
vaginal and anal sex. Information on age at first sex is important as it has implications on public
health policy. It also relates to specific unhealthy behavior that respondents did such as not using
condom during their first sex, abusing condom or having multiple partners. This could lead to
higher transmission of sexually-transmitted infection (STI), teen pregnancy and adverse
psychological consequences such as disappointment and regret (de Irala, Osorio, Carlos, Ruiz-
Canela, López-del Burgo, 2011).

3.4.2.2 Sexual Behavior with Male Partner and Condom Use

Risk behavior was identified from the number of male or female sex partners MSM respondents
have had in the last week. Afterwards, respondents were asked about any steady and non-steady
male partner, use of condom in their last sex encounter, and consistency in condom use in the last
month. In this survey, consistent condom use was defined as ‘often’ and ‘always’ using condom
during sex.

34
 Table 3.12 Sexual Behavior with Male Partner
Steady Male Partner Non-Steady Partner
Number of sex
Used Consistently
partners in the Used condom Consistently Had non-
Had steady condom used condom in
District/Municipality last week (male n during last used condom in steady male
male partner during last the last
and/or female) sex* the last month*^ partner
(%) sex* month*^
(Median) (%) (%) (%)
(%) (%)
Simeulue# 1 79 1.3 0.0 0.0 3.8 0.0 0.0
East Aceh# 2 66 28.8 57.9 42.1 36.4 66.7 42.9
Prabumulih City 1 250 40.4 77.2 60.0 59.6 67.8 52.5
Bandar
1 250 47.2 83.1 74.4 50.0 75.8 81.5
Lampung City
Batam City 1 250 38.4 65.6 63.4 50.4 82.5 76.4
South Jakarta
1 238 42.4 76.2 48.0 45.8 74.3 54.2
City
North Jakarta City 1 246 56.1 66.7 46.4 59.8 59.2 40.9
Bogor 2 258 54.3 76.4 30.0 64.7 76.6 30.6
Bogor City 1 242 40.5 71.4 62.0 68.2 60.6 61.8
Depok City 1 250 42.0 73.3 56.7 37.6 77.7 64.8
Surakarta City 2 233 31.3 68.5 53.4 54.1 84.1 65.0
Tegal City 2 224 22.8 68.6 56.9 35.3 64.6 58.5
Yogyakarta City 1 173 46.2 67.5 62.7 52.0 74.4 67.2
Pamekasan# 1 54 18.5 70.0 30.0 37.0 70.0 69.2
Blitar City# 1 51 49.0 72.0 65.2 56.9 48.3 61.5
Probolinggo City 3 120 43.3 53.8 3.8 44.2 50.9 9.5
Mojokerto City# 1 56 57.1 71.9 65.6 26.8 73.3 75.0
Tangerang 1 225 20.9 80.9 77.8 44.4 61.0 62.5
Cilegon City 1 187 23.5 68.2 53.5 58.3 52.3 39.2
Buleleng 1 248 73.4 61.5 11.0 50.0 73.4 8.7
Denpasar City 1 247 51.0 68.3 62.9 32.0 84.8 77.6
Mataram City 1 225 42.7 57.3 43.8 21.3 60.4 39.4
Manado City 1 244 45.5 57.7 51.8 37.7 73.9 57.4
Mimika 1 180 57.8 79.8 31.7 31.7 57.9 17.4

Aggregate 1 4290 43.4 69.6 47.9 47.4 69.9 51.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who had steady/non-steady partner; ^Respondents who did not have steady sex partners in the last month were
excluded from the denominator

Overall, almost half of MSM respondents had a steady male partner (43.4%). The highest
proportion was found in Buleleng District (73.4%) and 69.6% of MSM respondents reported
using condom in their last sex with their steady male partner. This implies relatively good
awareness about HIV and STI prevention; two-thirds of respondents knew preventive efforts that
have to be done during anal sex. However, condom use was not yet a routine behavior as less than
half of respondents (47.9%) used condom consistently in the last month. Among the 24
Districts/Municipalities where the 2018-2019 IBBS was conducted, the highest proportion of
MSM who used condom consistently with their steady partner was found in Tangerang District
(77.8%). This was linked to knowledge. Respondents with higher level of comprehensive
knowledge (48.9%) were also more consistent in using condom than respondents with less
knowledge (39.0%).

35
 A similar percentage of MSM, 47.4%, also had non-steady or casual male partners. Around 70%
of them used condom in their last sex with their casual partner. Consistent condom use was
reported at 51.0%, but only some MSM were aware about condom and actually used condom.
Intervention programs would still need to make intensive efforts to educate and raise awareness
about condom among the MSM community.

3.4.2.3 Sexual Behavior with Commercial Male Partner

The 2018-2019 IBBS also explored the characteristics of respondent’s commercial male partners,
either when respondents act as client (buy sex service) or as sex worker (sell sex).

Table 3.13 Sexual Behavior and Condom Use with Commercial Male Partner
Buy Sex from Men Sell Sex to Men

Age at first Used condom Used condom Age at first Used condom
Buy sex
District/Municipality n time buying during last consistently in the Sell sex to time selling consistently in
from men
sex* sex* last month** men (%) sex* the last month**
(%)
(median) (%) (%) (median) (%)

Simeulue# 79 0.0 NA NA NA 0.0 NA NA

East Aceh# 66 12.1 15 25.0 66.7 18.2 19.5 33.3
Prabumulih City 250 4.8 30 83.3 83.3 4.8 16.5 50.0
Bandar Lampung City 250 11.2 20 75.0 100.0 34.8 20 79.2
Batam City 250 3.2 24 62.5 50.0 30.8 20 78.8
South Jakarta City 238 19.7 24 68.1 53.8 30.7 21 60.0
North Jakarta City 246 18.7 22 58.7 26.1 36.6 21 49.0
Bogor 258 16.3 19 83.3 50.0 55.0 17 12.5
Bogor City 242 6.6 24 68.8 25.0 31.4 20 56.7
Depok City 250 6.8 22 70.6 50.0 17.2 21 52.6
Surakarta City 233 15.0 20 77.1 46.2 18.9 19.5 70.4
Tegal City 224 9.4 20 52.4 60.0 29.9 19 40.6
Yogyakarta City 173 10.4 24 61.1 0.0 13.9 19 50.0
Pamekasan# 54 0.0 NA NA NA 0.0 NA NA
Blitar City# 51 9.8 24 80.0 5.4 23.5 18 0.0
Probolinggo City 120 49.2 16 44.1 0.0 50.0 16 14.7
Mojokerto City# 56 8.9 27 60.0 100.0 32.1 18.5 75.0
Tangerang 225 4.0 23 44.4 75.0 14.2 19.5 90.9
Cilegon City 187 16.6 18 64.5 100.0 26.7 19 52.4
Buleleng 248 15.3 17 84.2 71.4 20.6 18 12.5
Denpasar City 247 9.3 25 78.3 16.7 26.7 22 86.7
Mataram City 225 8.9 20 30.0 50.0 12.9 19 62.5
Manado City 244 8.2 21 55.0 33.3 17.6 19 75.0
Mimika 180 7.2 19 84.6 0.0 4.4 20.5 100.0

Aggregate 4290 11,7 20 65,6 38,0 25,0 19 51

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who ever buy/sell sex; **Among respondents who bought/sold sex in the last month

In total 11.7% of MSM respondents bought sex service from other men, and they had been doing
so since the age of 20. Condom use in the last sexual encounter was reported by two-thirds of
respondents, but consistent use of condom was only 38%, indicating that not all respondents

36
 consistently used condom during sex. On average, respondents had paid sex with around 3 men
per month. This wide sexual network without consistent condom use would pose a high level of
risk for infection.

Studies reported that consistency in condom use during commercial sex is linked with one’s
perception of risk (AOR 1.92; 95%CI 1.22-3.01) (Ramanathan et al., 2013). A cross-tabulation of
the two variables showed that respondents who used condom consistently perceived themselves
to be at higher risk (81%) compared to respondents who did not use condom consistently
(53.3%).

As much as 25% of MSM respondents obtained income from selling sex to men. They had started
this work at the age of 19 and had around 5 clients per month. In Probolinggo City, half of the
MSM respondents already worked as sex workers when they were 16 years old. Overall, 51% of
respondents used condom consistently, except in Probolinggo City where consistent condom use
was very low, by only 14.7% of respondents.

Ramanathan, et al. (2013) reported that exposure to prevention interventions had some influence
on consistent condom use. This IBBS found a similar result that respondents who had contact
with an outreach worker to discuss HIV and STI transmission and prevention also had better
consistency in using condom (64.4%). As a comparison, respondents who never had any contact
with an outreach worker only used condom 43% of the time.

3.4.2.3 Sexual Behavior and Condom Use with Waria

Sexual behavior with waria gives indications on the type of anal sex that an MSM preferred, who
usually would like to be the insertive partner (Seekaew et al., 2019).

Table 3.14 Sexual Behavior and Condom Use with Waria

Anal Sex with Waria
Used Condom at Last Sexual Used Condom
District/Municipality n Anal Sex with Waria
Encounter with Waria* Consistently**
(%)
(%) (%)
Simeulue# 79 2.5 0.0 0.0
East Aceh# 66 6.1 50.0 50.0
Prabumulih City 250 10.8 59.3 30.0
Bandar Lampung City 250 7.6 57.9 80.0
Batam City 250 17.2 79.1 76.9
South Jakarta City 238 10.1 79.2 46.7
North Jakarta City 246 21.5 64.2 66.7
Bogor 258 2.7 85.7 0.0
Bogor City 242 5.0 50.0 37.5
Depok City 250 2.0 60.0 66.7
Surakarta City 233 31.3 69.9 36.4
Tegal City 224 58.5 42.7 35.6
Yogyakarta City 173 2.3 50.0 0.0
Pamekasan# 54 0.0 NA 0.0

37
 Anal Sex with Waria
Used Condom at Last Sexual Used Condom
District/Municipality n Anal Sex with Waria
Encounter with Waria* Consistently**
(%)
(%) (%)
Blitar City# 51 0.0 NA 0.0
Probolinggo City 120 20.8 40.0 12.5
Mojokerto City# 56 0.0 NA 0.0
Tangerang 225 34.7 76.9 77.1
Cilegon City 187 43.3 44.4 15.6
Buleleng 248 47.6 71.2 17.5
Denpasar City 247 6.9 82.4 85.7
Mataram City 225 7.6 70.6 41.7
Manado City 244 6.6 75.0 72.7
Mimika 180 1.7 66.7 0.0

Aggregate* 4290 17.6 62.2 39.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who had anal sex with waria; **Among respondents who had anal sex with waria in the last month

As an aggregate, 17.6% of MSM respondents reported having sex with waria, but the percentage
varied between district, and in Tegal City more than half (58.5%) of respondents had sex with
waria. Overall, 62.2% claimed to use condom in their last sexual encounter, but only 40% used
condom consistently in the last month. In fact, in some districts, such as Mimika District,
Yogyakarta City and Bogor District, no respondents used condom consistently (0%). This low
number could partly be due to the low risk perception that MSM had. As an insertive partner, they
are indeed at a lower risk for HIV transmission than an insertive partner but CDC (2019) had
stated that the HIV virus can still gain entry through the urethra, through small cuts, abrasions or
open cuts on the penis of the insertive partner.

3.4.2.4 Sexual Behavior and Condom Use with Female Partner

MSM’s sexual behavior with women was explored since 53% of MSM respondents also engaged
in vaginal sex, with a steady and non-steady female partner. A steady female partner was a
woman whom the respondent recognized or regarded as a willing sex partner in a committed
relationship that has lasted for at least three months. A steady female partner included wives also.
A non-steady partner was a woman who has non-paid casual sex with the respondent and was
not a steady sex partner of the respondent.

Table 3.15 Sexual Behavior and Condom Use with Female Partner
Steady Female Partner Non-Steady Female Partner

Had a steady Used condom Had a non- Used condom

Used condom Used condom
District/Municipality n female in last sex steady female in last sex with
consistently** consistently**
partner* with women** partner* women**
(%) (%)
(%) (%) (%) (%)

Simeulue# 23 73.9 0.0 0.0 8.7 0.0 0.0

East Aceh# 20 45.0 55.6 33.3 45.0 88.9 66.7
Prabumulih City 101 54.5 14.5 7.4 15.8 25.0 6.3

38
 Steady Female Partner Non-Steady Female Partner

Had a steady Used condom Had a non- Used condom

Used condom Used condom
District/Municipality n female in last sex steady female in last sex with
consistently** consistently**
partner* with women** partner* women**
(%) (%)
(%) (%) (%) (%)

Bandar Lampung City 141 51.1 45.8 40.0 23.4 42.4 18.2
Batam City 136 55.1 26.7 15.1 16.2 50.0 13.6
South Jakarta City 114 32.5 37.8 11.4 27.2 64.5 25.8
North Jakarta City 137 50.4 52.2 44.1 36.5 52.0 40.0
Bogor 80 58.8 48.9 19.1 21.3 64.7 35.3
Bogor City 126 37.3 40.4 34.0 24.6 54.8 45.2
Depok City 61 29.5 38.9 43.8 18.0 72.7 27.3
Surakarta City 128 58.6 34.7 28.0 53.9 43.5 33.3
Tegal City 166 55.4 28.3 25.0 74.7 29.8 25.0
Yogyakarta City 47 23.4 45.5 27.3 19.1 55.6 22.2
Pamekasan# 15 93.3 21.4 7.7 0.0 NA 0.0
Blitar City# 17 35.3 33.3 20.0 35.3 50.0 16.7
Probolinggo City 43 58.1 56.0 0.0 44.2 68.4 0.0
Mojokerto City# 13 23.1 66.7 33.3 53.8 28.6 14.3
Tangerang 119 32.8 43.6 23.1 37.0 56.8 22.7
Cilegon City 112 49.1 49.1 28.8 49.1 38.2 20.0
Buleleng 179 75.4 66.7 14.1 45.3 80.2 13.6
Denpasar City 130 27.7 47.2 45.2 12.3 50.0 37.5
Mataram City 186 55.9 42.3 37.5 24.7 47.8 28.3
Manado City 121 34.7 28.6 25.0 29.8 25.0 16.7
Mimika 144 31.3 57.8 51.1 20.1 75.9 34.5

Aggregate 2271 47.5 49.8 26.4 32.5 49.8 24.9

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who engaged in vaginal sex; ** Among respondents who had a steady female partner

As much as 47.5% of MSM respondents had a steady female partner (38% were wives). Almost
half (49.8%) used condom in their last sexual intercourse, and consistency in condom use with a
steady female partner was only 26.4%.

Among MSM respondents who had engaged in vaginal sex, a third also had non-steady female
partners, and 49.8% reported using condom in their last sexual encounter. Condom use
consistency in the last month was 25%.

This lack of consistency in condom use, in sex with both a steady and non-steady female partner,
was mostly due to trust (Pines et al., 2016). Not using condom demonstrated a high level of trust
in the partner. A steady partner was also an individual with whom the respondent had developed
an emotional bond or attachment and sex was something that was enjoyed but would result in
less pleasure when condom is used.

3.4.2.5 Sexual Behavior with Commercial Female Partner

To obtain a complete picture of MSM’s sexual behavior with women, information about their
sexual behavior, either buying sex from or selling sex to female partners was sought.

39
 Table 3.16 Sexual Behavior and Condom Use with Commercial Female Partner
Buy Sex from Women Sell Sex to Women

Bought sex Sold sex to

District/ Used condom Used condom Used condom Used condom
n from women in the
Municipality in last sex*** consistently*** in last sex**** consistently****
women* last year*
(%) (%) (%) (%)
(%) (%)

Simeulue# 23 4.3 NA 0.0 4.3 0.0 0.0

East Aceh# 20 10.0 NA 0.0 0.0 NA 0.0
Prabumulih
101 4.0 50.0 50.0 0.0 NA 0.0
City
Bandar
141 14.9 60.0 60.0 8.5 50.0 33.3
Lampung City
Batam City 136 11.0 0.0 3.7 80.0 0.0
South Jakarta
114 16.7 60.0 40.0 5.3 83.3 83.3
City
North Jakarta
137 30.7 81.3 62.5 21.9 73.3 50.0
City
Bogor 80 6.3 100.0 33.3 2.5 50.0 50.0
Bogor City 126 9.5 NA 0.0 6.3 87.5 37.5
Depok City 61 3.3 NA 0.0 0.0 0.0
Surakarta City 128 47.7 33.3 18.5 10.2 69.2 15.4
Tegal City 166 65.1 27.7 27.7 12.7 47.6 28.6

Yogyakarta City 47 19.1 NA 0.0 4.3 100.0 50.0

Pamekasan# 15 0.0 NA 0.0 0.0 NA 0.0

Blitar City# 17 5.9 NA 0.0 0.0 NA 0.0
Probolinggo
43 37.2 77.8 0.0 32.6 42.9 14.3
City

Mojokerto City# 13 15.4 NA 0.0 7.7 0.0 0.0

Tangerang 119 10.9 66.7 33.3 3.4 75.0 25.0

Cilegon City 112 19.6 54.5 45.5 10.7 58.3 50.0
Buleleng 179 27.4 90.9 9.1 20.1 94.4 13.9
Denpasar City 130 10.0 100.0 50.0 2.3 66.7 0.0
Mataram City 186 12.9 27.3 18.2 2.2 100.0 75.0
Manado City 121 8.3 0.0 0.0 6.6 25.0 25.0
Mimika 144 9.7 50.0 0.0 0.7 100.0 100.0

Aggregate 2271 20,2 48.7 27.3 8.0 69.1 31.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who engaged in vaginal sex; ** Among respondents who bought sex from women, *** Among respondents who bought
sex from women in the last month; **** Among respondents who sold sex to women in the last year; NA: Not Applicable, respondents
did not buy sex from women in the last month OR did not sell sex to women in the last year.

Sex with a paid female partner was done by 20.2% respondents, who generally had started doing
this at the age of 19. This was younger than the median age MSM bought sex from a male partner
(20 years old). Almost half, 48.7%, of respondents used condom in their last sex with a
commercial female partner, while 69.1% of respondents who sold sex to women used condom.
This shows that respondents were aware about HIV prevention, but this awareness had not been
internalized as part of their routine behavior as only a third of respondents used condom
consistently in paid sex.

40
 3.4.2.6 Sex Party and Other Risk Behavior
Another sexual behavior common to MSM was sex party. The survey aimed to obtain information
about respondent’s involvement and behavior in sex parties.

Table 3.17 Sex Party and Condom Use

Participated in sex party in Used condom in the last sex Changed condom when
District/ Municipality n the last year party* switched sex partner*
(%) (%) (%)
Simeulue# 79 0.0 NA NA
East Aceh# 66 3.0 50.0 50.0
Prabumulih City 250 2.0 100.0 100.0
Bandar Lampung City 250 8.4 85.7 71.4
Batam City 250 4.4 54.5 45.5
South Jakarta City 238 13.9 60.6 57.6
North Jakarta City 246 14.6 52.8 33.3
Bogor 258 1.2 66.7 33.3
Bogor City 242 7.0 64.7 47.1
Depok City 250 2.0 40.0 20.0
Surakarta City 233 9.9 91.3 47.8
Tegal City 224 25.9 32.8 13.8
Yogyakarta City 173 5.2 44.4 33.3
Pamekasan# 54 0.0
Blitar City# 51 5.9 33.3 0.0
Probolinggo City 120 11.7 57.1 64.3
Mojokerto City# 56 5.4 100.0 33.3
Tangerang 225 2.2 60.0 60.0
Cilegon City 187 8.6 56.3 56.3
Buleleng 248 1.6 100.0 100.0
Denpasar City 247 9.3 69.6 56.5
Mataram City 225 8.9 50.0 50.0
Manado City 244 5.3 61.5 38.5
Mimika 180 0.0 NA NA
Aggregate 4290 7.4 58.5 44.6
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who participated in sex parties in the last year.

A small proportion of MSM respondents (7.4%) reported attending sex parties in the last year. On
average respondents attended 3 sex parties, with around 7 participants. In the last party, almost
60% of respondents said they used condom, but when they switched partners, only 44.6%
respondents changed condoms.

The following table presents data on other risk behavior like alcohol consumption, and use of
drug before sex, use of injectable drugs, use of needles for tattooing or piercing.

41
 Table 3.18 Alcohol Consumption, Substance Abuse, Tattooing and Piercing among MSM

New needle New needle

Used drugs before Had
Drank alcohol in Had injected was used Had was used
District/ sex in the last 3 received
n the last 3 months drugs during piercing during
Municipality months tattoo
(%) (%) tattooing* (%) piercing*
(%) (%)
(%) (%)
Simeulue# 79 13.9 3.8 0.0 6.3 20.0 16.5 15.4
East Aceh# 66 4.5 3.0 0.0 1.5 100.0 4.5 66.7

Prabumulih City 250 50.4 12.0 0.4 16.4 65.9 6.4 50.0

Bandar
250 36.4 16.4 1.6 18.4 78.3 15.6 66.7
Lampung City
Batam City 250 33.6 28.0 1.6 18.4 76.1 39.6 80.8
South Jakarta
238 35.7 8.0 2.5 10.1 75.0 20.6 73.5
City
North Jakarta
246 38.2 11.8 0.8 10.2 68.0 19.9 67.3
City
Bogor 258 58.1 17.8 5.0 22.5 25.9 19.4 28.0
Bogor City 242 22.3 7.0 0.4 10.7 84.6 20.2 79.6
Depok City 250 18.0 1.2 0.4 3.2 100.0 8.0 80.0
Surakarta City 233 31.3 3.0 0.9 22.7 52.8 12.0 50.0
Tegal City 224 46.4 5.8 2.2 20.5 47.8 21.9 59.2

Yogyakarta City 173 8.1 2.3 0.0 2.9 60.0 8.1 85.7

Pamekasan# 54 3.7 0.0 0.0 0.0 NA 0.0 NA

Blitar City# 51 15.7 2.0 0.0 2.0 100.0 17.6 66.7

Probolinggo City 120 75.8 43.3 28.3 12.5 66.7 29.2 80.0

Mojokerto City# 56 25.0 3.6 0.0 0.0 NA 10.7 100.0

Tangerang 225 39.6 4.9 1.3 10.2 43.5 12.0 44.4

Cilegon City 187 34.8 3.7 0.5 11.2 61.9 22.5 73.8
Buleleng 248 81.9 7.3 1.6 36.7 87.9 63.7 77.2
Denpasar City 247 21.9 4.5 1.6 22.7 91.1 44.5 79.1
Mataram City 225 44.9 7.6 0.4 5.3 58.3 22.7 74.5
Manado City 244 56.6 6.1 1.2 20.5 84.0 39.3 70.8
Mimika 180 51.7 2.8 0.0 8.3 60.0 11.1 55.0

Aggregate 4290 40.9 9.7 2.1 15.4 68.5 23.2 70.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Around 41% of respondents consumed alcohol in the last three months. This was seen as one risk
factor for HIV transmission as alcohol could influence an individual’s cognitive capability and
caused him to follow his sexual urges without considering the risk and consequences. This could
lead to sex without condom (Shuper et al., 2017). Drugs also gave the same effect. The 2018-2019
IBBS found that 9.7% respondents in the last three months had been taking drugs before sex and
2.1% of respondents were also injecting drug users. Based on a study by Nerlander et al. (2018),
this group would be 5 times more likely to engage in anal sex without condom as well as share
needles.

Use of unclean non-sterile needle was also the main issue with regards to tattooing and piercing.
Among MSM who received the procedure, 68.5% of tattooing and 70.3% of piercing was done

42
 with fresh needle. However, there was still 31.5% and 29.7% of respondents who could
potentially be infected with HIV through non-sterile needles during tattoing and piercing.

3.5 Sexually-Transmitted Infection (STI)

3.5.1 Symptom and Testing

Sexually-transmitted Infection (STI) was one important component of the 2018-2019 IBBS, and
respondents were asked about any symptoms that they experienced in the last year. A total of
eight symptoms were asked, i.e. pain during urination, presence of wart and ulcer around the
genital area and anus, abnormal discharge from the penis and/or anus, and bumps/swelling
around the anal area. History of any STI test, place of test and any treatment that respondents
received was also asked. The table below only presents symptoms that related to ulcers around
the genital area, anus and abnormal discharge from the penis.

Table 3.19 STI Symptom and Testing among MSM

Symptoms Location of Last STI Test (%)
Had been
Ulcer in Ulcer in Abnormal Minimum
District/ 1 tested for
n the genital the anal discharge Private NGO Mobile
Municipality symptom STI Puskesmas Hospital Other
area area from penis (%) (%) Clinic Clinic VCT
(%) (%) (%)
Simeulue# 79 0.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA
East Aceh# 66 4.5 1.5 4.5 9,1 4.5 0.3 0.3 0.0 0.0 0.0 0.3
Prabumulih City 250 2.4 0.0 0.0 2,4 6.8 1.0 0.0 0.0 0.0 0.0 0.0
Bandar
250 1.6 1.6 5.2 7,2 16.8 0.7 0.2 0.1 0.0 0.0 0.0
Lampung City
Batam City 250 1.2 2.8 5.6 6,8 28.4 0.9 0.0 0.1 0.0 0.0 0.0
South Jakarta
238 1.3 1.7 2.9 5,9 55.5 0.6 0.0 0.4 0.0 0.0 0.0
City
North Jakarta
246 4.5 4.1 7.7 13,4 26.4 0.6 0.1 0.2 0.0 0.0 0.0
City
Bogor 258 0.8 0.0 1.9 2,3 5.8 0.8 0.0 0.1 0.1 0.0 0.0
Bogor City 242 2.1 1.2 11.2 12,0 33.1 0.8 0.1 0.1 0.0 0.0 0.0
Depok City 250 3.2 1.6 4.4 7,6 25.6 0.7 0.1 0.0 0.0 0.1 0.0
Surakarta City 233 0.9 0.4 1.7 2,2 12.4 0.7 0.2 0.0 0.1 0.1 0.0
Tegal City 224 2.7 1.3 1.3 5.4 11.2 0.6 0.1 0.1 0.0 0.1 0.1
Yogyakarta City 173 4.6 6.4 11.0 19.1 51.4 0.6 0.2 0.1 0.0 0.1 0.0
Pamekasan# 54 0.0 0.0 0.0 0.0 0.0 NA NA NA NA NA NA
Blitar City# 51 7.8 7.8 13.7 21.7 19.6 0.5 0.3 0.1 0.0 0.0 0.1
Probolinggo
120 3.3 0.8 1.7 5.0 13.3 0.9 0.0 0.0 0.0 0.0 0.1
City
Mojokerto City# 56 0.0 0.0 7.1 7.1 46.4 0.7 0.1 0.0 0.0 0.1 0.0
Tangerang 225 0.4 0.0 0.9 1.3 19.1 0.7 0.0 0.1 0.0 0.2 0.0
Cilegon City 187 2.1 0.0 2.7 4.8 16.0 0.9 0.1 0.0 0.0 0.0 0.0
Buleleng 248 6.9 0.8 3.6 11.3 21.8 1.0 0.0 0.0 0.0 0.0 0.0
Denpasar City 247 6.1 5.7 19.4 24.7 59.9 0.4 0.1 0.4 0.1 0.0 0.1
Mataram City 225 1.3 1.3 13.3 14.7 19.6 0.8 0.0 0.0 0.0 0.2 0.0
Manado City 244 2.9 1.6 6.6 9.8 36.1 0.1 0.1 0.8 0.0 0.0 0.0
Mimika 180 1.7 0.0 1.1 2.2 7.8 0.6 0.1 0.1 0.0 0.1 0.0

43
 Symptoms Location of Last STI Test (%)
Had been
Ulcer in Ulcer in Abnormal Minimum
District/ 1 tested for
n the genital the anal discharge Private NGO Mobile
Municipality symptom STI Puskesmas Hospital Other
area area from penis (%) (%) Clinic Clinic VCT
(%) (%) (%)
Aggregate 4290 2.6 1.7 5.5 8.4 24.8 63.7 7.2 20.9 2.3 4.2 1.7
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *is a composite
variable from several variables of STI symptoms that respondents experienced; **Based on the number of respondents who had STI
tests

As seen in the above table, abnormal discharge from the penis was the most common symptom
reported by respondents (5.5%). Other STI symptoms were experienced between 1.7%-2.6% of
the time. These proportions of symptom did not match the result of specimen testing for syphilis,
gonorrhea and chlamydia. For example, based on laboratory testing, 9.6% of respondents had
syphilis (Figure 3.1), while the main symptoms of syphilis like ulcers around the genital area and
anus were only experienced by 2.74% and 2.44% of respondents. This may be possible as syphilis
has a relatively long incubation period of 9-90 days before an open sore (chancre) would appear.
The patient may also not feel pain, and chancres tend to heal spontaneously within 4-6 weeks
such that the patient will usually not seek treatment.

The above symptoms were then combined into an aggregate to separate respondents who never
experienced any STI symptoms in the last year, from respondents who experienced at least one
symptom. Interview was subsequently performed to get information about care-seeking behavior
of respondents who experienced symptoms.

Data showed that 8.4% of respondents experienced at least one STI symptom. More respondents
however underwent STI test (24.8%), and they mostly went to Puskesmas (63.7%). This shows
that in the era of JKN (National Health Insurance), Puskesmas has become the facility of choice
for STI testing. Insurance coverage by BPJS (public insurance administrator) also facilitated
access to health service.

Some respondents (47.4%) consulted a health provider for the STI symptoms they experienced.
Cross-tabulation showed that consulting health provider was done by 86.5% respondents with
genital or anal ulcer or abnormal penile discharge. This finding was consistent with the result of
a study by Purnama and Sari (2018) that recorded 46.5% MSM went to a health provider or health
facility.

3.5.2 STI Treatment

This section describes the care-seeking behavior of respondents who experienced STI symptoms.
The survey also sought information about places respondents visited for STI treatment, type of
up-to-date STI testing in the last six months prior to the interview. Data about recommendations
for respondents’ steady partners to also get STI test were obtained.

44
 Table 3.20 STI Treatment for MSM
Went to a Health Location of STI Treatment** (%) Had STI Tests Recommend STI
Provider when
in the last 6 Test to steady
District/Municipality N* experienced STI Puskesmas/ Doctor’s
Other Months partner**,^
Symptoms* Hospital Practice (%) (%)
(%)
Simeulue# 0 NA NA NA NA NA 0.0
East Aceh# 3 33.3 100.0 0.0 0.0 1.6 40.0
Prabumulih City 17 35.3 100.0 0.0 0.0 1.7 31.3
Bandar Lampung City 42 42.9 66.7 33.3 0.0 0.5 64.5
Batam City 71 52.1 86.5 10.8 2.7 5.0 71.4
South Jakarta City 132 69.7 94.6 3.3 2.2 5.7 84.2
North Jakarta City 65 47.7 74.2 22.6 3.2 5.0 42.9
Bogor 15 46.7 100.0 0.0 0.0 2.9 59.1
Bogor City 80 48.8 87.2 12.8 0.0 0.0 76.5
Depok City 64 35.9 91.3 8.7 0.0 4.3 73.3
Surakarta City 29 58.6 82.4 11.8 5.9 2.5 35.7
Tegal City 25 60.0 80.0 20.0 0.0 0.5 46.9
Yogyakarta City 89 53.9 79.2 12.5 8.3 0.0 NA
Pamekasan# 0 NA NA NA NA NA NA
Blitar City# 10 50.0 100.0 0.0 0.0 0.0 NA
Probolinggo City 16 6.3 100.0 0.0 0.0 14.4 100.0
Mojokerto City# 26 15.4 75.0 0.0 25.0 6.7 53.3
Tangerang 43 53.5 95.7 0.0 4.3 9.3 33.3
Cilegon City 30 33.3 90.0 0.0 10.0 12.7 37.5
Buleleng 54 33.3 83.3 11.1 5.6 23.7 82.9
Denpasar City 148 39.2 79.3 6.9 13.8 1.0 76.2
Mataram City 44 50.0 95.5 4.5 0.0 0.0 74.2
Manado City 88 44.3 53.8 25.6 20.5 0.0 100.0
Mimika 14 7.1 100.0 0.0 0.0 0.0 0.0

Aggregate 1066 47.4 83.6 10.9 5.5 3.5 62.9

*Respondents who had STI tests; **Respondents who went to a health provider; ^The answer category of not having a steady partner
was taken out of the denominator

The above table shows that less than half of MSM respondents (47.4%) sought care from a health
provider upon experiencing STI symptoms. Several large studies in other countries also found
similarly low rate of care-seeking behavior among MSM, which was thought to be because people
tended to postpone seeking care until symptoms became serious enough. MSM mostly chose to
self-treat mild symptoms with antibiotics or let the symptoms resolve spontaneously (Xu et al.,
2017). In this survey, the highest proportion of respondents who sought care from a health
provider was those who had abnormal discharge from the penis (27.3%), followed by those who
had wart or ulcer around the genital (8.1%) and anus (5.7%).

Health facility that most respondents visited for STI service was Puskesmas/Hospital (83.6%).
This was not surprising considering STI treatment at Puskesmas is already part of the Ministry of
Health program and medication and treatment cost is covered by the government.

As high-risk groups, MSM should ideally undergo frequent STI test. The HIV Control Book
recommends that risk populations undergo STI test every three months. This report presents

45
 results of STI testing that was performed in the last six months to obtain a broader picture of the
STI situation. Unfortunately, only 3.5% of respondents had STI test in the last six months, and in
some Districts/Municipalities (Bogor City, Yogya City, Mataram City, Manado City, Mimika), the
proportion was even zero. This reflected respondents’ low awareness about STI or limited
experience with STI symptoms as only 5.5% respondents reported having any STI symptoms.

As many as 62.9% of respondents also made suggestions to their steady partner to get tested for
STI. This shows respondent’s care over their steady partner. MSM does have a strong sense of
belonging to their community and their steady partner, particularly a male partner.

3.6 HIV Test and Treatment

Data on the coverage of HIV program is presented as a continuum of care starting from testing, to
treatment. The HIV/AIDS care cascade starts with HIV testing, receipt of result, notification of
result, ARV treatment and follow-on test like viral load test to evaluate treatment effectiveness.

3.6.1 HIV Test and Testing Location

HIV test and testing locations are listed in Table 3.21 below.

Table 3.21 HIV Test and Location of Last HIV Test

HIV Test Location of Last HIV Test* HIV
Yes, on own Test in
District/ Yes, on
n Yes, based initiative and n Private NGO Mobile the last
Municipality own Never Puskesmas Hospital Other
on referral based on Clinic Clinic VCT 1 year
initiative
referral (%)
Simeulue# 79 0.0 0.0 0.0 100.0
East Aceh# 66 9.1 1.5 1.5 87.9 8 25.0 25.0 37.5 12.5 0.0 0.0 37.5
Prabumulih
250 6.8 2.8 3.2 87.2 32 81.3 0.0 0.0 0.0 18.8 0.0 96.9
City
Bandar
250 32.0 6.8 19.6 41.6 146 83.6 8.9 0.7 0.7 4.8 1.4 87.0
Lampung City
Batam City 250 28.4 2.0 22.4 47.2 132 66.7 24.2 3.0 1.5 4.5 0.0 80.3
South Jakarta
238 47.5 13.4 11.8 27.3 173 54.9 2.9 32.9 1.7 4.6 2.9 83.2
City
North Jakarta
246 13.8 4.9 9.3 72.0 69 65.2 17.4 13.0 1.4 2.9 0.0 92.8
City
Bogor 258 14.3 4.7 39.5 41.5 151 70.9 2.6 2.6 10.6 13.2 0.0 91.4
Bogor City 242 32.2 18.6 27.7 21.5 190 68.9 7.9 1.6 0.5 20.5 0.5 74.7
Depok City 250 49.2 2.8 32.0 16.0 210 70.0 6.7 1.4 4.3 16.7 1.0 91.4
Surakarta City 233 7.7 15.5 49.4 27.5 169 79.9 4.7 0.6 5.3 9.5 0.0 97.0
Tegal City 224 5.8 18.8 11.2 64.3 80 76.3 3.8 1.3 8.8 8.8 1.3 96.3
Yogyakarta
173 52.0 4.6 26.0 17.3 143 51.7 6.3 0.7 14.7 22.4 4.2 83.9
City
Pamekasan# 54 0.0 0.0 0.0 100.0
Blitar City# 60 26.7 26.7 8.3 38.3 28 46.4 42.9 3.6 0.0 3.6 3.6 51.4
Probolinggo
177 33.9 33.9 5.1 27.1 72 86.1 6.9 4.2 0.0 2.8 0.0 52.7
City

46
 HIV Test Location of Last HIV Test* HIV
Yes, on own Test in
District/ Yes, on
n Yes, based initiative and n Private NGO Mobile the last
Municipality own Never Puskesmas Hospital Other
on referral based on Clinic Clinic VCT 1 year
initiative
referral (%)
Mojokerto
75 38.7 38.7 8.0 14.7 45 71.1 13.3 0.0 0.0 15.6 0.0 65.6
City#
Tangerang 216 14.4 14.4 48.1 23.1 175 66.9 1.7 0.6 0.0 30.9 0.0 97.0
Cilegon City 242 29.3 29.3 3.3 38.0 95 87.4 1.1 1.1 0.0 10.5 0.0 58.0
Buleleng 348 36.8 36.8 2.3 24.1 164 93.3 1.2 0.0 4.9 0.6 0.0 61.4
Denpasar City 336 36.3 36.3 16.1 11.3 209 35.9 5.7 38.8 12.9 2.4 4.3 63.8
Mataram City 277 22.7 22.7 9.0 45.5 99 51.5 18.2 0.0 1.0 27.3 2.0 63.6
Manado City 286 33.6 33.6 5.2 27.6 165 60.6 10.9 20.6 1.8 4.2 1.8 58.0
Mimika 229 22.7 22.7 0.4 54.1 56 41.1 10.7 14.3 0.0 32.1 1.8 44.8
Aggregate 4290 30.2 9.6 19.2 41 2530 67.0 7.1 8.4 4.3 11.9 1.3 88.5
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who had HIV test

As much as 59.0% of MSM respondents had been tested for HIV, on their own initiative (30.2%),
based on referral (9.6%) and both on their initiative as well as received referral for testing
(19.2%). The proportion of MSM who took the initiative to get tested was larger than the
proportion of those who got tested due to referral, demonstrating good self-awareness among
the MSM respondents.

The most common location of HIV test was Puskesmas (67.0%). In some regions, the percentage
was even higher than 80%, like in Prabumulih City (81.3%), Bandar Lampung City (83.6%),
Probolinggo City (86.1%), Cilegon City (87.4%) and Buleleng District (93.3%). Mobile VCT
(voluntary counseling and testing) service was the second most common test site (11.2%). Mobile
VCT is service that is provided near the MSM gathering place, outside a health facility as one way
to bring services closer to the target population. Its availability means service programs were
already able to identify MSM’s gathering places in each region. For a closed community like MSM,
gaining trust becomes a fundamental principle so that MSM would be willing to receive service
from service providers.

3.6.2 Reason for Getting or Not Getting HIV Test

The coverage of HIV testing still needs to be increased, since as listed in Table 3.21 only 51% of
MSM respondents got tested for HIV. Reasons for getting or not getting tested therefore need to
be identified so that appropriate and accurate interventions can be implemented.

47
 Table 3.22 Reason for Getting or Not Getting HIV Test
Reasons for Getting HIV Test*,^(%) Reasons for Not Getting HIV Test **,^(%)

District/ Recomm Recomm. by Do not Do not Do not

n For n know
Municipality Feels at .by a a field/ Recomm. Test site want to know
Informatio Other Expensive need Other
risk health outreach by a friend far away know testing HIV
n Letter
provider worker status site test
Simeulue# 0 NA NA NA NA NA NA 79 0.0 0.0 0.0 0.0 100.0 0.0
East Aceh # 8 25.0 25.0 12.5 0.0 0.0 37.5 59 36.8 0.0 21.1 21.1 21.1 0.0
Prabumulih
32 0.0 43.8 6.3 50.0 0.0 0.0 239 0.0 0.0 20.5 20.5 46.4 12.5
City
Bandar
146 1.4 84.2 3.4 2.1 2.1 6.8 108 1.6 1.6 22.6 22.6 46.8 4.8
Lampung City
Batam City 132 0.0 74.2 3.8 7.6 3.0 11.4 124 3.4 0.0 31.0 31.0 17.2 17.2
South Jakarta
173 1.2 77.5 5.2 2.9 3.5 9.8 56 0.0 6.5 12.9 12.9 58.1 9.7
City
North Jakarta
69 0.0 76.8 1.4 13.0 0.0 8.7 232 0.0 0.0 38.1 38.1 18.1 5.6
City
Bogor 151 0.7 48.3 9.9 32.5 3.3 5.3 124 1.5 0.0 29.9 29.9 31.3 7.5

Bogor City 190 0.5 48.4 3.7 20.5 9.5 17.4 58 2.6 0.0 17.9 17.9 48.7 12.8
Depok City 210 1.0 74.8 1.9 15.2 2.9 4.3 51 19.5 0.0 26.8 26.8 24.4 2.4
Surakarta City 169 0.0 41.4 5.9 47.9 2.4 2.4 66 0.0 0.0 9.4 9.4 81.3 0.0
Tegal City 80 0.0 42.5 3.8 35.0 17.5 1.3 131 0.0 0.0 0.0 0.0 100.0 0.0
Yogyakarta
143 0.7 44.1 2.1 4.9 3.5 44.8 28 5.0 0.0 20.0 20.0 10.0 45.0
City
Pamekasan# 0 NA NA NA NA NA NA 54 0.0 0.0 0.0 0.0 100.0 0.0
Blitar City# 37 0.0 46.4 17.9 3.6 3.6 28.6 19 0.0 0.0 13.3 13.3 40.0 33.3
Probolinggo
129 25.0 18.1 12.5 5.6 1.4 37.5 49 16.7 16.7 16.7 16.7 33.3 0.0
City
Mojokerto
64 0.0 60.0 11.1 4.4 15.6 8.9 11 14.3 0.0 28.6 28.6 0.0 28.6
City#
Tangerang 166 1.1 37.1 10.3 48.0 1.7 1.7 57 1.9 0.0 18.9 18.9 60.4 0.0
Cilegon City 150 2.1 87.4 0.0 3.2 3.2 4.2 63 15.8 0.0 26.3 26.3 31.6 0.0

Buleleng 264 13.4 66.5 3.0 13.4 1.2 2.4 85 0.0 0.0 14.0 14.0 72.0 0.0

Denpasar City 298 30.1 33.0 3.3 7.2 4.8 21.5 30 0.0 0.0 22.2 22.2 11.1 44.4
Mataram City 151 11.1 32.3 3.0 30.3 9.1 14.1 122 0.0 0.0 12.3 12.3 65.8 9.6

Manado City 207 3.6 70.3 3.6 5.5 9.1 7.9 65 4.3 0.0 17.4 17.4 39.1 21.7
Mimika 5.4 21.4 21.4 3.6 32.1 16.1 126 0.0 0.0 25.0 25.0 25.0 25.0

Aggregate 2530 5.4 55.7 4.9 17.7 5 11.3 1760 2.1 0.5 22.3 16.2 50.7 8.2
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Respondents’ most common reason to get tested was a perception that they were at risk (55.7%).
As a factor that promotes testing, risk perception could also be increased through meetings and
discussion with health provider/field worker/outreach worker, or through educational media.
Another reason for testing was suggestion from a health provider (17.7%). This shows that field
workers have an important and essential role in promoting HIV test.

Among respondents who have not been tested their main reason was not knowing that they
needed HIV test (50.7%). This related to their low level of knowledge regarding the importance
of HIV test, since only 49.7% respondents had ever met/discussed about HIV with an outreach
field worker.

48
 3.6.3 Consent, Counseling and Receipt of HIV Test Result

Before an HIV test, several ethical aspects need to be observed, namely individuals who are
getting a test need to consent to a blood sample collection, and need to receive pre- and post-test
counseling. The table below presents the proportion of respondents who received their test
results in less than 2 hours. Two hours were determined as the maximum time an individual
would be willing to wait. If the patient decided to go home because the waiting period is longer
than two hours, he/she would need additional time, energy and transport cost to return to the
health facility to pick up the result. This increased the probability the patient would not return to
pick up the test result, with the consequence that they would not know their HIV status.

Table 3.23 Consent, Counseling and Receipt of HIV Test Result

For respondents who have had HIV tests
Received test result Suggest HIV test
Consent for blood Received counseling in less than 2 to steady partner
District/Municipality n Received the test
draw was obtained before getting the hours* *^
result (%)
(%) result (%) (%) (%)

Simeulue# 0 NA NA NA NA NA
East Aceh# 8 37.5 37.5 25.0 100.0 100.0
Prabumulih City 32 96.9 90.6 84.4 96.3 25.0
Bandar Lampung City 146 99.3 98.6 97.3 97.2 53.8
Batam City 132 100.0 99.2 97.0 93.8 50.4
South Jakarta City 173 97.7 96.5 96.0 92.8 70.8
North Jakarta City 69 98.6 100.0 97.1 88.1 80.4
Bogor 151 100.0 99.3 94.7 95.1 25.7
Bogor City 190 97.9 96.3 94.2 89.9 59.2
Depok City 210 98.6 99.0 97.6 97.6 76.1
Surakarta City 169 99.4 99.4 91.7 75.5 54.3
Tegal City 80 100.0 97.5 86.3 97.1 47.7
Yogyakarta City 143 98.6 97.9 98.6 97.2 81.9
Pamekasan# 0 NA NA NA NA NA
Blitar City# 37 82.1 78.6 85.7 54.2 73.3
Probolinggo City 129 70.8 55.6 50.0 63.9 52.9
Mojokerto City# 64 100.0 95.6 93.3 92.9 93.1
Tangerang 166 98.3 97.7 98.9 98.8 57.8
Cilegon City 150 96.8 95.8 92.6 89.8 54.8
Buleleng 264 92.7 97.0 98.8 92.0 17.0
Denpasar City 298 95.7 91.4 97.6 92.6 85.6
Mataram City 151 100.0 97.0 97.0 97.9 55.1
Manado City 207 97.0 98.8 96.4 96.9 69.9

Mimika 105 96.4 85.7 76.8 97.7 47.4

Aggregate 2530 97.2 95.9 94.2 93.0 56.8

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who received the result of their last HIV test; ^the category of not having a steady partner had been taken out of the
denominator.

49
 Practically all the respondents (97.2%) who had HIV tests were asked for consent for a blood
sample collection. In some Districts/Municipalities, the percentage was 100% (Bogor District,
Tegal City and Mataram City). Consent was given either in writing or verbally.

Up till now HIV is still considered as a frightening disease such that before giving patients their
test result, counseling should be provided to help them be mentally prepared, regardless of the
test result. Almost all of the respondents did receive counseling before receiving their test result.
This pre-test counseling is part of the Voluntary Counselling and Testing (VCT) procedure and is
mandatory to be given. Unfortunately, among the 24 Districts/Municipalities of survey sites,
North Jakarta City was the only place that fulfilled its obligation of 100% pre-test counseling.
Counseling is given with the objective to provide psychological support and help presumptive
HIV patient make changes toward healthy and safe behaviors. Counseling also serves to give
information about risk behavior in order to prevent HIV transmission.

Results of HIV test were received by only 94.2% respondents. That meant that there were some
who still did not have clear information about their HIV status, which would be very dangerous if
these individuals turned out to be positive. Having no knowledge about their test result would
lead them to believe they were not infected, which may cause them to not make any prevention
efforts. Among those who did receive their test result, around 4% claimed they still did not know
for certain the result of their test.

The time period between testing and receipt of result was important to increase the coverage of
test result receipt. The above table shows that 93.0% of respondents received their test result
relatively quickly, i.e. 2 hours. This actually still needs to be improved since based on the Minister
of Health Regulation Number 74/2014 about Guideline for HIV Counseling and Testing, result of
HIV testing should be available in less than 2 hours.

Among respondents who received their last HIV test result, only 56.8% suggested to their steady
partner to get HIV test. This low percentage may reflect respondents’ fear that their partner may
be suspicious. Cross-tabulation between disclosing HIV test result and suggesting HIV test to a
steady partner showed that 53% of respondents who were open about their test result would
suggest their steady partner to get tested as well. On the other hand, among respondents who
were not open about their test result, only 26.7% recommended HIV test to their steady partner.

Following data about HIV test and result, information about ARV treatment and evaluation using
viral load test is presented.

Table 3.24 HIV Treatment and Viral Load Test among MSM

Viral Had viral load Received

Received Are still taking Stopped taking Result of
District/ Received CST Load test in the last
n1 ARV2 ARV until now3 ARV for 3 Viral Load
Municipality Service1 (%) Test2 12 months
(%) (%) months4 (%) Test5
(%) (%)
(%)
Simeulue# 0

50
 Viral Had viral load Received
Received Are still taking Stopped taking Result of
District/ Received CST Load test in the last
n1 ARV2 ARV until now3 ARV for 3 Viral Load
Municipality Service1 (%) Test2 12 months
(%) (%) months4 (%) Test5
(%) (%)
(%)
East Aceh# 0
Prabumulih City 20
Bandar
28 95.0 100.0 94.7 25.0 89.5 94.1 94.1
Lampung City
Batam City 30 85.7 95.8 95.7 4.5 29.2 71.4 71.4
South Jakarta
20 73.3 95.5 95.2 0.0 63.6 50.0 92.9
City
North Jakarta City 6 70.0 100.0 100.0 14.3 71.4 80.0 80.0
Bogor 58 66.7 100.0 75.0 33.3 50.0 0.0 100.0
Bogor City 16 96.6 100.0 100.0 8.9 53.6 73.3 96.7
Depok City 9 87.5 100.0 100.0 14.3 78.6 90.9 72.7
Surakarta City 9 100.0 88.9 87.5 14.3 11.1 100.0 100.0
Tegal City 23 77.8 85.7 100.0 16.7 28.6 100.0 50.0
Yogyakarta City 87.0 100.0 100.0 5.0 65.0 69.2 69.2
Pamekasan# 11
Blitar City# 0 100.0 100.0 90.9 0.0 45.5 60.0 60.0
Probolinggo City 3
Mojokerto City# 13 100.0 100.0 100.0 0.0 33.3 100.0 100.0
Tangerang 3 100.0 100.0 100.0 15.4 23.1 100.0 66.7
Cilegon City 4 66.7 100.0 100.0 50.0 50.0 0.0 100.0
Buleleng 36 25.0 100.0 100.0 100.0 100.0 100.0 100.0
Denpasar City 7 97.2 97.1 91.2 6.5 57.1 85.0 100.0
Mataram City 75 85.7 100.0 100.0 0.0 83.3 100.0 80.0
Manado City 2 96.0 100.0 97.1 16.4 26.4 63.2 89.5
Mimika 0 100.0 100.0 100.0 0.0 100.0 100.0 100.0

Aggregate 349 89.7 97.4 96.7 11.5 48.9 75.8 88.2

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; 1Among

respondents with positive HIV test; 2Based on the number of respondents who received CST service; 3Based on the number of
respondents who received ARV; 4Based on the number of respondents who are still taking ARV until now; 5Based on the number of
respondents who had viral load test; Note: In Prabumulih City, Pamekasan and Probolinggo, no respondents reported any positive
HIV test results.

From MSM respondents who received their HIV test result, 349 were positive (based on
respondent’s statement in the behavioral questionnaire), but only 89.7% received CST (care,
support and treatment) service. Antiretroviral (ARV) treatment was provided to 97.4%
respondents, and up to a month prior to the survey interview, 96.7% of respondents who had
enrolled in ARV therapy were still receiving the life-saving treatment. Viral load test was provided
to 48.9% respondents in CST service, and 139 of them received the viral load test result (88. 2%).

3.7 Tuberculosis (TB)

The 2018-2019 IBBS also collected information about TB interventions that MSM respondents
received. First, respondents were asked about any TB symptoms that they experienced in the last
year, also any TB tests and treatment package that they received. Lastly, respondents were asked
if HIV test was offered to them at the time of the TB test.

51
 Table 3.25 TB Symptoms, Testing and Treatment that MSM Experienced
TB Examination and Testing
Had coughs for >2 Received TB Offered HIV Test
District/ Had been to a health Knew the TB Test
n weeks in the last 1 Treatment during TB Service*
Municipality facility for TB test* Result*
year (%) Package* (%) (%)
(%) (%)
Simeulue# 79 5.1 2.5 50.0 50.0 0.0
East Aceh# 66 12.1 3.0 0.0 0.0 0.0
Prabumulih City 250 2.8 0.0
Bandar
250 8.0 11.2 89.3 21.4 35.7
Lampung City
Batam City 250 6.0 6.4 100.0 25.0 12.5
South Jakarta
238 8.4 9.2 90.9 9.1 36.4
City
North Jakarta City 246 13.4 12.2 96.7 10.0 40.0
Bogor 258 6.2 3.9 60.0 20.0 60.0
Bogor City 242 14.0 12.8 100.0 45.2 41.9
Depok City 250 6.0 7.6 100.0 42.1 63.2
Surakarta City 233 13.3 3.0 100.0 14.3 71.4
Tegal City 224 16.1 8.5 84.2 21.1 31.6
Yogyakarta City 173 13.9 15.6 77.8 7.4 29.6
Pamekasan# 54 0.0 0.0
Blitar City# 51 27.5 27.5 78.6 28.6 14.3
Probolinggo City 120 21.7 11.7 64.3 50.0 35.7
Mojokerto City# 56 5.4 8.9 100.0 0.0 80.0
Tangerang 225 3.1 3.1 85.7 28.6 14.3
Cilegon City 187 15.0 2.1 75.0 75.0 50.0
Buleleng 248 4.4 1.6 100.0 50.0 100.0
Denpasar City 247 13.4 13.8 94.1 5.9 26.5
Mataram City 225 6.7 3.6 100.0 0.0 25.0
Manado City 244 16.4 17.2 95.2 57.1 57.1
Mimika 180 2.8 3.3 83.3 0.0 66.7

Aggregate 4290 9.7 7.6 90.5 26.2 40.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who had TB test

Coughs that last for more than 2 weeks is one key symptom of TB, and 9.7% MSM respondents
experienced it in the last year. However, only 7.6% of them went to a health facility for TB testing
and 26.2% of them received TB treatment package. It is assumed that they were those who got a
positive diagnosis of TB. Based on the Minister of Health Regulation Number 21/2013, HIV
counseling and testing can be initiated by health providers (provider-initiated testing and
counseling – PITC), and every patient in TB service should be tested for HIV. However, the above
table shows that less than half of MSM respondents in TB service was offered HIV test (40.5%).

3.8 Hepatitis
The 2018-2019 IBBS also looked at the coverage of Hepatitis program, and collected data on
Hepatitis B and C test that MSM respondents received, the test result and the treatment provided
(specifically for Hepatitis C). The variable on knowing the Hepatitis test result was obtained from

52
recoding of the question on Hepatitis test result. Respondents were also asked about their
Hepatitis B immunization status.

Table 3.26 Hepatitis Testing and Treatment among MSM

Had been
Know the Hep Had Hep B Had been Know the Receive
tested for
District/ Municipality n B Test result* Immunization* tested for Hep C Test treatment for
Hepatitis B
(%) (%) Hep C (%) result* (%) Hep C** (%)
(%)
Simeulue# 79 0.0 NA NA 0.0 NA NA
East Aceh# 66 0.0 NA NA 0.0 NA NA
Prabumulih City 250 0.0 NA NA 0.0 NA NA
Bandar Lampung City 250 23.6 100.0 70.6 18.1 100.0 100.0
Batam City 250 14.7 90.0 50.0 2.9 100.0 NA
South Jakarta City 238 29.2 95.2 47.6 26.4 94.7 NA
North Jakarta City 246 61.2 86.7 26.7 67.3 90.9 100.0
Bogor 258 21.4 88.9 33.3 9.5 75.0
Bogor City 242 25.3 100.0 52.6 17.3 100.0 100,0
Depok City 250 43.9 96.0 24.0 29.8 94.1 100,0
Surakarta City 233 0.0 0.0 NA 0.0 0.0 NA
Tegal City 224 14.7 100.0 60.0 5.9 100.0 NA
Yogyakarta City 173 26.7 92.6 29.6 8.9 100.0 NA
Pamekasan# 54 0.0 0.0 NA 0.0 0.0 NA
Blitar City# 51 31.3 100.0 100.0 6.3 100.0 NA
Probolinggo City 120 20.0 0.0 0.0 20.0 100.0 NA
Mojokerto City# 56 58.1 100.0 22.2 29.0 100.0 NA
Tangerang 225 0.0 0.0 NA 0.0 0.0 NA
Cilegon City 187 23.8 80.0 20.0 9.5 100.0 NA
Buleleng 248 75.0 100.0 33.3 25.0 100.0 100.0
Denpasar City 247 25.9 95.2 33.3 19.8 93.8 100.0
Mataram City 225 0.0 0.0 NA 0.0 0.0 NA
Manado City 244 57.9 61.4 22.7 5.3 75.0 NA
Mimika 180 26.3 93.3 53.3 17.5 90.0 NA
Aggregate* 4290 5.9 88.1 36.5 3.4 93.8 100.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who had been tested for Hepatitis: **Among respondents with positive Hepatitis test result.

Overall, only 5.9% of MSM respondents were tested for Hepatitis B and from that number, 88.1%
received their test result, and 36.5% of them were immunized against Hepatitis B. The number of
respondents who stated they were Hepatitis B positive was 19 people.

For Hepatitis C, 3.4% respondents were tested, less than those who had Hepatitis B test (5.9%).
Among those who were tested for Hepatitis C, 93.8% received their test result, and 4.8% were
positive for Hepatitis C. All respondents who had a positive Hepatitis C test also received
treatment for Hepatitis C (100%).

53
 3.9 Coverage of Other Prevention Program
Other prevention programs are services that rely on field outreach workers to approach and
reach out to key populations. The table below presents respondents’ experience with prevention
program in the form of one-on-one meetings or group meetings with field outreach workers,
attendance at HIV/AIDS educational activities, receipt of printed/audio-visual materials on HIV,
receipt of free condoms as well as efforts to contact a text messaging or hotline service on HIV.

Table 3.27 MSM’s Exposure to HIV Prevention Program

Receive
Attend an Receive free Contacted by Contact a Contact a
Discuss with a printed/
District/ edutainment condom an outreach Text Hotline
n health provider audio-visual
Municipality on HIV from a worker Messaging Service
(%) materials on
(%) provider (%) (%) Center (%) (%)
HIV (%)

Simeulue# 79 0.0 0.0 0.0 0.0 0.0 0.0 0.0

East Aceh# 66 3.0 0.0 3.0 1.5 0.0 1.5 1.5
Prabumulih City 250 12.4 2.4 26.4 26.0 12.0 1.2 0.0
Bandar
250 26.4 18.0 36.8 24.8 20.0 4.8 1.6
Lampung City
Batam City 250 10.8 3.6 6.0 14.0 23.6 1.2 0.4
South Jakarta City 238 12.6 8.8 13.9 13.4 10.5 3.4 1.7
North Jakarta City 246 23.6 14.6 33.7 21.5 16.7 26.4 9.8
Bogor 258 14.7 21.7 39.1 40.3 27.5 11.2 5.4
Bogor City 242 46.3 14.0 55.8 17.4 33.5 4.5 2.1
Depok City 250 29.6 13.2 24.8 19.2 30.4 6.8 1.2
Surakarta City 233 27.0 13.7 54.1 62.2 57.1 8.2 22.7
Tegal City 224 14.7 12.9 20.5 11.2 13.8 3.6 0.9
Yogyakarta City 173 41.0 20.8 38.2 20.2 34.1 4.6 2.9
Pamekasan# 54 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Blitar City# 51 11.8 2.0 43.1 0.0 3.9 11.8 2.0
Probolinggo City 120 14.2 65.0 70.8 45.8 47.5 31.7 33.3
Mojokerto City# 56 64.3 67.9 35.7 32.1 33.9 10.7 8.9
Tangerang 225 20.9 12.0 42.2 49.3 36.9 7.1 6.2
Cilegon City 187 12.3 10.2 9.1 15.0 16.0 8.6 5.3
Buleleng 248 44.4 19.0 62.5 57.3 60.5 34.7 30.2
Denpasar City 247 37.7 12.6 38.9 30.8 32.4 4.5 2.4
Mataram City 225 20.9 5.3 23.6 15.6 16.9 2.7 0.9
Manado City 244 30.7 18.0 29.1 18.9 13.9 3.3 5.7
Mimika 180 6.7 2.8 21.1 1.7 0.6 0.6 0.6

Aggregate* 4290 23.9 14.0 33.5 26.7 24.5 8.6 6.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The survey recorded that only 23.9% respondents had ever had a discussion about HIV
prevention and transmission with a health provider, which demonstrates the low coverage of HIV
prevention program among MSM. Other prevention interventions include edutainment events

54
 and distribution of printed or audio-visual materials about HIV. However, these programs at the
most could only reach about a third of respondents.

Getting free condoms was reported by 26.7% respondents, which was slightly higher than the
proportion (24.5%) who had contact with an outreach worker in the last three months. A small
proportion of respondents also pro-actively contacted a text messaging service (8.6%) or hotline
service (6.5%).

In general, it can be said that respondents’ exposure to HIV prevention programs was still very
low, which may be due to inability of sufficient number of outreach workers to gain entry to the
MSM community. A study conducted by Riani, Shaluhiyah and Widagdo (2014) reported that
target achievement of MSM outreach program was limited as the community was still relatively
closed and unwilling to disclose their identity to outsiders.

HIV prevention programs also provided education in the form of meeting and discussion sessions
facilitated by outreach field workers. HIV-related information would be presented at those
sessions, as detailed in Table 3.27 below. In this table, respondents could give more than one
answer.

Table 3.28 Type of Information MSM Receive from Field Outreach Workers

Information Received from Field Outreach Workers

District/ Drug/ Safe Basic CST for

n HIV HIV Peer Support
Municipality Injection / Condom Health STI PLHIV TB PMTCT
Transmission Testing Group
Overdose (%) Care (%) (ART) (%) (%)
(%) (%) (%)
(%) (%) (%)

Simeulue# 79 1.3 1.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Aceh Timur# 66 0.0 4.5 4.5 6.1 1.5 3.0 1.5 3.0 3.0 0.0
Prabumulih City 250 17.6 44.0 52.8 35.6 18.0 31.2 50.8 14.4 13.6 5.6
Kota Bandar
250 18.8 28.4 45.6 24.0 17.6 32.0 21.6 13.2 9.6 4.0
Lampung
Batam City 250 22.0 62.0 61.6 54.8 6.8 10.0 61.6 6.8 4.8 1.6
Kota Jakarta
238 9.7 44.5 48.7 42.0 11.3 37.0 38.2 8.8 5.0 2.1
Selatan
North Jakarta City 246 29.7 44.7 43.9 39.0 26.4 24.4 32.1 21.5 18.3 11.8
Bogor 258 5.8 40.7 55.8 36.8 9.3 6.6 16.3 7.8 4.7 1.9
Bogor City 242 22.3 65.3 73.6 62.0 41.3 27.3 45.5 35.5 25.6 16.1
Depok City 250 6.0 44.4 56.4 32.4 7.2 8.8 14.0 5.6 3.6 2.0
Surakarta City 233 2.6 59.2 66.1 54.5 8.6 6.9 41.6 3.0 25.8 0.0
Tegal City 224 7.1 20.5 23.2 16.5 8.0 8.0 8.9 4.0 3.6 0.4
Yogyakarta City 173 22.5 69.4 72.3 63.6 26.0 41.0 57.2 30.6 18.5 19.7
Pamekasan# 54 5.6 1.9 1.9 0.0 0.0 0.0 0.0 0.0 1.9 0.0
Blitar City# 51 3.9 31.4 27.5 17.6 5.9 17.6 13.7 13.7 7.8 2.0
Probolinggo City 120 30.8 33.3 42.5 28.3 21.7 25.0 20.8 6.7 0.0 0.0
Mojokerto City# 56 21.4 67.9 67.9 57.1 46.4 44.6 55.4 41.1 21.4 8.9
Tangerang 225 2.2 79.1 79.1 68.9 6.7 4.4 17.8 4.4 1.8 0.4
Cilegon City 187 3.2 29.9 44.9 29.9 1.1 3.2 12.3 0.5 1.6 0.0
Buleleng 248 40.7 46.8 24.6 41.9 0.8 1.6 2.8 0.0 0.0 0.0
Denpasar City 247 21.5 69.6 73.3 59.9 13.4 23.1 55.9 18.2 10.5 6.5
Mataram City 225 13.3 28.0 32.0 20.4 6.7 6.7 20.4 4.0 4.0 1.3

55
 Information Received from Field Outreach Workers

District/ Drug/ Safe Basic CST for

n HIV HIV Peer Support
Municipality Injection / Condom Health STI PLHIV TB PMTCT
Transmission Testing Group
Overdose (%) Care (%) (ART) (%) (%)
(%) (%) (%)
(%) (%) (%)
Manado City 244 4.9 31.1 29.1 22.1 13.1 13.5 18.0 7.8 2.5 0.4
Mimika 180 3.9 12.2 9.4 7.2 0.6 1.1 0.6 0.6 0.6 0.6

Aggregate 4290 14.9 45.5 49.7 39.4 12.8 16.3 28.7 10.3 8.4 3.9

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples ; PMTCT =
Prevention of Mother to Child Transmission

The above data shows that the type of information respondents received most frequently from
field outreach workers revolved around about HIV testing (49.7%) and HIV transmission
(45.5%). This finding was reflected in respondents’ testing and prevention behavior. About 59%
of MSM respondents received HIV test, either on their own initiative and/or referred by someone
else.

In meetings with field workers, information about HIV would be presented, which then improved
respondents’ knowledge, as well as awareness about HIV.

3.10 Positivity Rate

Positivity rates in the MSM group were calculated using aggregate data from 19
Districts/Municipalities. The other 5 Districts/Municipalities were not included in the aggregate
analysis due to insufficient number of samples.

HIV and syphilis tests were results from 4355 and 4354 respondents respectively. A positive HIV
test meant a reactive result on anti-HIV test. For treatment purposes, a positive syphilis test
would generally be further categorized into reactive, early-stage or late-stage syphilis based on
the level of infection, however in the 2018/2019 IBBS syphilis was presented as positive without
further differentiation. An additional category of false positive was presented for results that
were inconsistent where the individual had a reactive result on syphilis rapid test, but non-
reactive on the titer test.

Hepatitis B and C test was performed only in three Districts/Municipalities in West Java Province,
totalling to 750 MSM.

Chlamydia and Gonorrhea test was performed to 801 respondents in five selected
Districts/Municipalities. Two Districts with low number of samples – Simeuleu District with 69
samples and East Aceh District with 68 samples – were taken out of the aggregate calculation of
Chlamydia, Gonorrhea and Chlamydia-Gonorrhea mixed infection among MSM. The total samples
included were 658. Positivity rate of Chlamydia-Gonorrhea (CT/NG) mixed infection was also
calculated, in addition to the positivity rate of a single infection.

56
The proportion of Chlamydia and Gonorrhea cases were combined with the proportion of CT/NG
case to illustrate the magnitude of the problem with Chlamydia and Gonorrhea more
comprehensively.

Figure 3.1 Positivity Rate of HIV, STI and Hepatitis in MSM Respondents

The above graph illustrates that overall MSM had quite a high burden of disease. Prevalence of
chronic diseases like HIV, Syphilis and Hepatitis B ranged between 5.1% - 17.9%, while the
prevalence of acute infections like Chlamydia, Gonorrhea and Chlamydia-Gonorrhea dual
infection was even higher at 12% to 27.1%.

The high prevalence of HIV, Syphilis and Hepatitis B among MSM showed that protective behavior
(consistent condom use) was still low, ranging from 57.7% (with non-steady male partner) to
62.4% (with male partner during paid sex). Sexual network was also another factor. The broader
an individual sexual network was, the higher the risk for transmission would be. One
characteristic of the MSM community is the high number of sex partners each MSM had, from
men, waria, and women as steady and non-steady partners, to commercial partners (buying and
selling sexual service) and partners during sex parties. Seven respondents (0.3%) did
acknowledge having all those types of partners. In general, 72.7% of MSM respondents had at
least two types of partners.

In light of the information above, educational activities to improve MSM’s knowledge, and
awareness about condom use, along with other prevention efforts such as promoting being
faithful to one’s partner need to be intensified. Exposure to prevention programs and encounter

57
 with field outreach workers is currently limited. One strategy to increase exposure would be to
take advantage of social media that almost all MSM respondents are actively involved in.

Acute infection was one health burden of the MSM community as a result of low condom use.
Acute infections spread very quickly, requiring only one-time exposure to an infected individual.

Table 3.29 Positivity Rate of HIV, STI and Hepatitis in MSM per District/Municipality

HIV Syphilis CT/NG CT NG Hep B Hep C

Kabupaten Kota n n
n % n % (%) (%) (%) (%) (%)
Simeulue# 67 0.0 67 0.0 69 0.0 1.4 0.0
Aceh Timur# 9.1 66 0.0 68 1.5 4.4 3.0

Prabumulih City 0.0 250 3.6

Bandar
250 21.6 250 4.0
Lampung City
Batam City 250 19.6 250 16.4
South Jakarta
238 28.2 238 16.0
City
North Jakarta
17.9 245 14.7
City

Bogor 12.0 258 3.5 258 0.8 0.0

Bogor City 38.4 242 16.9 242 10.3 0.0

Depok City

Surakarta City 9.4 233 14.2

Tegal City 4.0 224 4.9

Yogyakarta City 27.7 172 7.0 169 9.5 27.3 16.0

Pamekasan# 7.4 54 1.9

Blitar City# 51 41.2 50 16.0

Kota
119 10.1 119 0.8
Probolinggo

Mojokerto City# 26.8 56 23.2

Tangerang 11.2 224 7.1

Cilegon City 7.5 187 6.4

Buleleng 4.0 248 1.6

Denpasar City 38.1 244 20.5 247 13.8 28.4 19.1

Mataram City 9.8 225 8.9

Manado City 40.2 244 14.3

Mimika 2.2 180 2.8

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The proportion of HIV cases in the 24 Districts/Municipalities varied greatly, from 0% (in
Prabumulih City) to 40.2% (in Manado City). This large difference implied that there was a large

58
gap in respondents’ knowledge, behavior and exposure to HIV prevention program in each
District/Municipality.

Data in the above table also shows that several cities had a syphilis prevalence above 10%. They
were the City of Batam (16.40%), South Jakarta (15.20%), North Jakarta (14.46%), Bogor
(16.40%), Depok (14.00%), Surakarta (13.47%), Denpasar (20.5%) and Manado (14.00%). These
are all large cities that tend to have a higher prevalence of syphilis than small
Districts/Municipalities. A similar trend was also observed in China as reported by Zhou et al.
(2014).
Among the MSM respondents in five selected Districts/Municipalities where Chlamydia and
Gonorrhea tests were performed, Denpasar City had the highest prevalence of Chlamydia (28.4%)
and Gonorrhea (19.1%), as well as the mixed infection of Chlamydia and Gonorrhea (CT/NG)
13.77%.

For Hepatitis B, in the three Districts/Municipalities where data was collected, the highest
prevalence, i.e. 10% was found in Bogor City. This was twice the prevalence in Depok City and 12
times the prevalence in Bogor District. Hepatitis C was only detected in Depok City.

59
 Waria
This chapter describes the 2018-2019 IBBS findings for the waria community that include the
prevalence of HIV, Syphilis, Chlamydia, Gonorrhea, Hepatitis B and C along with some
characteristics of waria. Risk factors that may contribute to HIV transmission such as level of
knowledge, risk perception, risk behavior and access to health care are also described.

Waria (Wanita-pria / Female-Male) is one group that is at high risk for STI and HIV infection.
Waria is an individually who is biologically male, but identify themselves as female or waria. The
operational definition of waria that the IBBS used was male aged at least 15 years who identify
himself as female (waria), has had sex with men minimally in the last year and has resided in the
survey city for at least one month.

In the 2018-2019 IBBS, data on waria was collected from 21 Districts/Municipalities in 13

selected provinces. The target was to recruit 5250 respondents, 250 from each
District/Municipality. Up to the end of data collection, a total of 3053 respondents were recruited
for the behavioral component and 3116 respondents had their samples taken for the biological
component of the survey.

The planned and actual number of samples collected in each District/Municipality is listed in the
table below:

Table 4.1 Number of Samples Targeted, Collected, and Rate of Participation among Waria

Actual Coverage Actual Coverage

No Provinces District/Municipality Plan
(Behavioral Data) (%) (Biological Data) (%)
1 Aceh Aceh Besar 250 63 25.2 64 25.6

2 North Sumatra Pematang Siantar City 250 249 99.6 250 100.0

3 250 234 93.6 248 99.2

South Sumatra Palembang City

4 Lampung Bandar Lampung City 250 134 53.6 134 53.6

5 Riau Islands Tanjung Pinang City 250 54 21.6 54 21.6

6 DKI Jakarta West Jakarta City 250 224 89.6 223 89.2

7 Bogor 250 250 100.0 250 100.0

8 Purwakarta 250 250 100.0 250 100.0

West Java
9 Bekasi 250 250 100.0 250 100.0

10 Depok City 250 200 80.0 200 80.0

11 Yogyakarta Yogyakarta City 250 100 40.0 101 40.4

12 East Java Banyumas 250 120 48.0 120 48.0

13 Banyuwangi 250 105 42.0 105 42.0

14 Sumenep 250 215 86.0 250 100.0

15 Mojokerto City 250 24 9.6 24 9.6

16 Madiun City 250 22 8.8 22 8.8

60
 Actual Coverage Actual Coverage
No Provinces District/Municipality Plan
(Behavioral Data) (%) (Biological Data) (%)
17 Surabaya City 250 209 83.6 209 83.6

18 NTT Kupang City 250 15 6.0 15 6.0

19 West 250 220 88.0 220 88.0

Pontianak City
Kalimantan
20 Central 250 43 17.2 50 20.0
Palangka Raya City
Kalimantan
21 Maluku Ambon City 250 72 28.8 77 30.8

Total 5250 3053 58.15 3116 59.35

The above table shows that data was able to be collected in all planned sites, but the number of
questionnaires completed did not reach the targeted number. Rate of participation for the
behavioral component of the survey was 58.15% while for the biological component the rate was
slightly higher at 59.35%. Some waria were willing to undergo biological test but were not willing
to be interviewed.

The highest rate of participation for both the behavioral and biological component was obtained
in three Districts in West Java, i.e. the District of Bogor (100%), Bekasi (100%), and Purwakarta
(100%). As many as 7 Districts/Municipalities had a lower than 40% participation rate, namely
Aceh Besar District (25.2%), Tanjung Pinang City (21.6%), Mojokerto City (9.6%), Madiun City
(8.8%), Kupang City (6%), Palangka Raya City (17.2% for the behavioral component and 20% for
the biological component) and Ambon City (28.8% and 30.8% for the behavioral and biological
component respectively).

4.1 Respondent Characteristics

HIV-related risk and behavior varied according to the socio-demographic characteristics of the
at-risk population, including factors like age, marital status, etc. Knowledge about the diversity in
the waria community is hoped to provide a clearer picture about the HIV situation among waria.

The next section describes the characteristics of waria in terms of age, level of education, marital
status, living arrangement, main employment and health insurance coverage.

Table 4.2 Age Group and Educational Level of Waria

Age of Waria (%) Educational Level of Waria (%)

Median Never Elementary High
District/Municipality n 15-19 20-24 25-49 ≥50 Jr.High Sch/ College/
Age went to School/ School/
years years years years school Equivalent University
Equivalent Equivalent
Aceh Besar# 63 28 7.9 27.0 65.1 0.0 0.0 4.8 4.8 77.8 12.7

249 30 10.8 16.9 70.7 1.6 0.4 14.9 32.5 47.4 4.8
Pematang Siantar City

Palembang City 234 36 1.3 11.5 74.8 12.4 0.4 15.8 32.5 47.0 4.3

Bandar Lampung City 9.0 36.6 51.5 3.0 0.7 7.5 28.4 59.0 4.5
134 25

61
 Age of Waria (%) Educational Level of Waria (%)
Median Never Elementary High
District/Municipality n 15-19 20-24 25-49 ≥50 Jr.High Sch/ College/
Age went to School/ School/
years years years years school Equivalent University
Equivalent Equivalent
Tanjung Pinang City# 54 33 0.0 13.0 77.8 9.3 0.0 16.7 11.1 59.3 13.0

West Jakarta City 224 30 8.0 16.5 73.7 1.8 0.9 12.5 42.9 42.4 1.3

Bogor 250 30 2.0 15.6 76.0 6.4 2.8 35.2 46.8 14.0 1.2

Purwakarta 250 31 2.0 16.0 75.6 6.4 2.4 26.0 31.6 38.8 1.2

Bekasi 250 34 1.6 10.4 83.2 4.8 3.6 31.2 36.0 29.2 0.0

Depok City 200 34 0.0 5.5 93.0 1.5 0.0 3.0 38.0 55.5 3.5

Banyumas 120 28 20.0 20.8 52.5 6.7 0.0 19.2 31.7 40.0 9.2

Yogyakarta City 100 43 0.0 4.0 64.0 32.0 2.0 21.0 24.0 44.0 9.0

Banyuwangi 105 32 7.6 18.1 60.0 14.3 4.8 34.3 28.6 30.5 1.9

Sumenep 215 35 0.9 6.5 81.9 10.7 3.3 38.6 24.2 27.0 7.0

Mojokerto City# 24 31 0.0 25.0 70.8 4.2 0.0 20.8 37.5 41.7 0.0

Madiun City# 22 33 0.0 13.6 68.2 18.2 0.0 9.1 13.6 68.2 9.1

Surabaya City 209 38 0.5 9.6 79.9 10.0 0.5 19.6 22.0 53.6 4.3

Kupang City# 15 30 0.0 0.0 100.0 0.0 0.0 6.7 40.0 53.3 0.0

Pontianak City 220 29 0.0 18.6 78.2 3.2 1.4 13.2 39.1 45.0 1.4

Palangka Raya City# 43 35 9.3 11.6 72.1 7.0 0.0 11.6 34.9 41.9 11.6

Ambon City# 72 26 9.7 23.6 65.3 1.4 1.4 1.4 11.1 73.6 12.5

Aggregate 2760 3.9 14.3 74.7 7.0 1.6 21.1 33.7 40.3 3.4 3,4
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Overall, the median age of waria respondents was 32 years (Table 4.2), but in each
District/Municipality the median age was actually lower and quite variable. The youngest was 25
years old (in Bandar Lampung City) and the oldest was 43 years (in Yogyakarta City). As an
aggregate, the majority of respondents (74.7%) was between 25-49 years of age. Quite a few of
respondents (18.2%) were younger than 25 years; 14.3% were between 20-24 years, and 3.9%
were even younger at 15 to 19 years of age. This shows that the waria community is quite
vulnerable to HIV infection.

In all survey sites, the highest proportion of respondents was from the 25-to 49-year age group.
The proportion of different age groups varied between sites. The highest proportion of the young
adolescent waria (15-19 years) was found in Banyumas District (20.0%), while the young adults
who were between 20-24 years of age were mostly found in Bandar Lampung City (36.6%). In
Depok City, almost all (93%) of the waria respondents were between 25 to 49 years old, and older
waria respondents who were ≥50 years were mostly found in Yogyakarta City (32%).
Overall, there was still a small proportion of respondents (1.6%) who never went to school. About
a third, 33.7%, completed the 9 years of mandatory schooling (up to junior high school) while the
majority of respondents (40.3%) completed high school. A small proportion (3.4%) of
respondents also had a university degree. Cross tabulation between educational level and

62
 HIV/AIDS information showed that 83.87% respondents who had higher education and 86.32%
respondents who completed high school had received information about HIV/AIDS. In contrast,
only 57.78% of respondents who never went to school received HIV/AIDS information. This
shows how level of education played a role in one’s exposure to HIV-related information, the more
educated an individual was, the more likely he/she would have accurate knowledge about
HIV/AIDS.

Site-wise, Bandar Lampung City had the highest proportion of respondents who completed high
school (59%), while Banyumas District had the largest number of respondents with a higher
education degree (9.2%). Waria respondents who never went to school were mostly found in
Banyuwangi District (4.8%), while 8 Districts/Municipalities had zero respondents who never
went to school.

Table 4.3 Marital Status and Living Arrangement of Waria

Marital Status (%) Living Arrangement (%)

District/ With With wife or
Municipality With With
n Unmarried Married Divorced n* Alone waria/male female steady Other
friends family
steady partner partner
Aceh Besar# 63 96.8 3.2 0.0 54 11.1 57.4 27.8 0.0 3.7 0.0

Pematang 90.8 6.0 3.2 206 17.5 32.5 44.7 1.9 3.4 0.0
249
Siantar City
Palembang City 234 88.9 9.0 2.1 204 17.6 29.4 46.6 1.5 4.4 0.5

Bandar 88.8 4.5 6.7 126 28.6 17.5 48.4 4.0 1.6 0.0
134
Lampung City
Tanjung 98.1 1.9 0.0 49 34.7 8.2 55.1 2.0 0.0 0.0
54
Pinang City #
West Jakarta 92.9 3.6 3.6 179 40.2 43.0 12.3 3.9 0.6 0.0
224
City
Bogor 250 98.0 0.0 2.0 239 52.7 29.3 15.9 2.1 0.0 0.0

Purwakarta 250 86.4 6.4 7.2 233 40.8 21.9 32.6 3.4 0.9 0.4

Bekasi 250 94.0 1.2 4.8 230 69.1 15.7 10.0 4.3 0.9 0.0

Depok City 200 95.0 2.5 2.5 200 81.5 11.5 2.0 2.5 2.5 0.0

Banyumas 120 85.0 10.0 5.0 113 16.8 13.3 63.7 4.4 1.8 0.0

Yogyakarta City 100 91.0 5.0 4.0 97 56.7 21.6 16.5 1.0 2.1 2.1

Banyuwangi 105 92.4 1.0 6.7 102 17.6 2.9 74.5 3.9 1.0 0.0

Sumenep 215 94.0 3.3 2.8 206 42.7 17.5 36.4 0.5 2.4 0.5

Mojokerto City# 24 95.8 4.2 0.0 21 33.3 4.8 57.1 4.8 0.0 0.0

Madiun City# 22 100.0 0.0 0.0 18 66.7 16.7 11.1 5.6 0.0 0.0

Surabaya City 209 88.0 2.4 9.6 208 59.6 3.4 22.1 13.0 1.4 0.5

Kupang City# 15 100.0 0.0 0.0 15 53.3 6.7 33.3 0.0 0.0 6.7

Pontianak City 220 99.1 0.0 0.9 218 36.2 22.5 30.7 10.6 0.0 0.0

Palangka 88.4 2.3 9.3 43 20.9 32.6 34.9 11.6 0.0 0.0
43
Raya City #
Ambon City# 72 94.4 4.2 1.4 67 41.8 10.4 44.8 1.5 1.5 0.0

Aggregate 2760 92.1 3.8 4.1 2561 43.2 21.0 29.8 4.2 1.6 0.2

63
 #These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of waria
with a permanent place to live

All the waria respondents were interviewed about their marital status, which is presented as
three groups: unmarried, married, and divorced. Being married was defined as being legally
married and were either living together or separately from the spouse. The ‘Divorced’ category
included respondents who were divorced or widowed. As an aggregate, 3.8% respondents were
married, 66.3% lived with their spouse, and 33.7% lived separately from their spouse. The
majority of waria respondents were unmarried (92.1%) and 4.1% were divorced. A study by
Kposowa (2013) on marital status and HIV reported that marriage provides a more stable sex life
so married respondents should have their biological needs met much better compared with
unmarried respondents. Unmarried or divorced individuals were likely to have multiple sex
partners which would put them at higher risk for HIV infection.

Location-wise, unmarried respondents were equally distributed among all the

Districts/Municipalities with the highest proportion in Pontianak City and Bogor District (99.1%
and 98.0% respectively). The highest proportion of married respondents was found in Banyumas
District (10.0%) while divorced respondents were mostly found in Surabaya City (9.6%) relative
to the other sites.

Waria respondents were also asked whether they lived alone, with their family or another person.
This information was hoped to provide a picture of respondents’ vulnerability toward risk
behaviors or practices. Living alone may cause respondents to be more likely to engage in risky
behavior due to lack of control from family or friends. Overall, 43.2% of respondents lived alone,
as they were unmarried. Other living arrangement included living with family (29.8%), with
friends (21.0%), with a wife or steady female partner (1.6%) and with a steady waria/male
partner (4.2%).

The highest proportion of respondents who lived alone was found in Depok City (81.5%) while
the highest proportion of respondents who lived with friends was found in West Jakarta City
(43.0%), and those who lived with a waria/male partner was mostly found in Surabaya City
(13.0%).

Table 4.4 Employment, Health Insurance Coverage and Circumcision Status of Waria

Employment of Waria (%) Health Insurance (%)

Circum
District/ Job with Job with Free- Government
n Government Private No cision
Municipality Unemployed steady non-steady lance and Private
Insurance Insurance Insurance Status
income income Work Insurance
Aceh Besar# 63 6.3 30.2 15.9 47.6 90.5 0.0 1.6 7.9 100.0

Pematang Siantar
249 4.4 12.0 24.1 59.4 30.9 0.4 1.2 67.5 74.3
City
Palembang City 234 0.4 3.4 41.0 55.1 37.2 0.9 1.7 60.3 100.0
Bandar Lampung
134 8.2 22.4 49.3 20.1 50.0 3.7 0.7 45.5 99.3
City
Tanjung Pinang
54 25.9 46.3 13.0 14.8 68.5 1.9 1.9 27.8 98.1
City #

64
 Employment of Waria (%) Health Insurance (%)
Circum
District/ Job with Job with Free- Government
n Government Private No cision
Municipality Unemployed steady non-steady lance and Private
Insurance Insurance Insurance Status
income income Work Insurance

West Jakarta City 224 14.3 14.7 24.1 46.9 69.6 0.0 0.4 29.9 96.9
Bogor 250 2.4 2.8 12.8 82.0 14.8 0.4 0.8 84.0 100.0

Purwakarta 250 9.6 19.2 52.4 18.8 27.2 0.4 0.0 72.4 99.2

Bekasi 250 9.2 7.2 13.6 70.0 30.4 0.4 4.4 64.8 98.4

Depok City 200 13.0 8.0 73.0 6.0 19.0 0.0 2.0 79.0 98.0

Banyumas 120 22.5 33.3 15.8 28.3 57.5 0.8 0.8 40.8 96.7

Yogyakarta City 100 5.0 9.0 23.0 63.0 51.0 3.0 1.0 45.0 96.0

Banyuwangi 105 4.8 8.6 44.8 41.9 21.9 1.0 2.9 74.3 100.0

Sumenep 215 12.6 6.5 46.5 34.4 20.0 2.3 0.9 76.7 98.1
Mojokerto City# 24 0.0 54.2 29.2 16.7 41.7 0.0 0.0 58.3 100.0

Madiun City# 22 0.0 4.5 81.8 13.6 59.1 0.0 0.0 40.9 100.0

Surabaya City 209 9.6 47.4 6.2 36.8 43.1 0.5 0.0 56.5 97.6
Kupang City# 15 0.0 20.0 20.0 60.0 46.7 0.0 0.0 53.3 40.0

Pontianak City 220 4.1 22.3 45.5 28.2 15.5 0.0 2.3 82.3 93.2

Palangka Raya City # 43 14.0 7.0 16.3 62.8 46.5 4.7 2.3 46.5 100.0
Ambon City# 72 18.1 47.2 11.1 23.6 33.3 5.6 2.8 58.3 70.8

Aggregate 2760 8.2 14.9 33.4 43.6 33.2 0.8 1.4 64.6 95.9
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

All waria respondents were asked about employment or their source of income, and data was
categorized not based on the type of occupation, but on the consistency in receiving a monthly
income. As an aggregate, the most common type of occupation that respondents had was free-
lance work (43.6%) or not a specific steady job. Respondents without a fixed monthly income
were 33.4%, while those with a fixed monthly income were 14.9%, and those who were
unemployed were 8.2%. This last group may be less likely to access health care compared to those
who were employed. Cross-tabulation between respondents’ employment and HIV test shows
that 44.9% of respondents who did not obtain HIV test were those who were unemployed, while
among the employed respondents, only 19.3% did not get tested. The highest proportion of
unemployed respondents was found in Banyumas district (22.5%), while the majority of those
with a fixed monthly income was found in Mojokerto City (54.2%), and the majority of
respondents with free-lance work was found in Bogor District (82.0%),

Information about ownership of health insurance was also collected as waria was one group that
is at-risk of being infected with STI and HIV, and would therefore need health insurance coverage.
Overall, 64.6% of respondents did not have health insurance, which was quite high. These waria
respondents would be facing a large financial risk because if they became ill, they would have to
fund their health care on their own. Meanwhile 33.2% of respondents had public health insurance
and 0.8% had private health insurance. The majority of those with public health insurance resided
in West Jakarta City (69.6%) while those with private health insurance was mostly found in

65
 Bandar Lampung City (3.7%). The highest proportion of respondents with no health insurance
was found in Bogor District (84.0%).

Circumcision status was another important variable as circumcision is one factor that can prevent
HIV transmission among waria respondents. Zhang (2019) did a meta analysis on this factor and
reported that the rate of infection among circumcised individuals was 30% lower than the rate
among those who were uncircumcised. In the aggregate data of this survey, the majority of waria
had been circumcised (95.9%), and in some sites (Palembang City, Bogor District and
Banyuwangi District), 100% of respondents were circumcised.

4.2 Virtual Network

This section presents information about internet access, sites frequented by respondents, their
exposure to information, and online communication efforts that they did.

Table 4.5 Internet Access, Information Search, and Online Communication of Waria

Member of Access Website/

Access the Visit Waria- Communicate
District/ Mailing List/ Internet to find
n Internet related Websites Online about HIV
Municipality Instant Information on
(%) (%) (%)
Messenger (%) HIV (%)
Aceh Besar# 63 100.0 22.2 14.3 14.3 9.5
Pematang Siantar City 249 94.4 42.6 8.8 4.4 3.6

Palembang City 234 82.1 18.4 15.4 15.8 7.3

Bandar Lampung City 134 94.8 45.5 18.7 16.4 8.2

Tanjung Pinang City # 54 83.3 50.0 44.4 42.6 40.7

West Jakarta City 224 38.4 5.8 4.5 2.2 1.8

Bogor 250 62.4 38.4 21.6 18.4 12.8

Purwakarta 250 81.2 21.2 10.4 13.2 7.2

Bekasi 250 85.6 4.8 12.0 5.6 4.4

Depok City 200 91.5 39.5 11.5 10.5 5.5

Banyumas 120 96.7 54.2 34.2 8.3 6.7

Yogyakarta City 100 77.0 45.0 61.0 21.0 14.0

Banyuwangi 105 83.8 0.0 1.0 1.9 0.0

Sumenep 215 66.5 24.2 20.0 14.9 1.4

Mojokerto City# 24 83.3 54.2 83.3 45.8 33.3

Madiun City# 22 40.9 27.3 4.5 0.0 0.0

Surabaya City 209 84.2 2.4 4.8 20.6 15.8

Kupang City# 15 100.0 100.0 100.0 46.7 46.7

Pontianak City 220 88.2 4.1 4.1 5.9 5.0

Palangka Raya City# 43 72.1 39.5 20.9 18.6 9.3

Ambon City# 72 91.7 25.0 31.9 25.0 12.5

Aggregate 2760 79.3 23.1 14.2 11.2 6.6

66
 #These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

As Table 4.5 shows, 79.3% of respondents had access to internet. The highest proportion was
found in Banyumas District (96.7%). Waria respondents liked to visit waria-related websites.
Overall 23.1% did that, but the highest proportion was found in Banyumas District (54.2%).
Waria respondents also joined a mailing list/used an instant messaging application. The majority
(61.0%) was found in Yogyakarta City, while as an aggregate the proportion was 14.2%. Easy
internet access should basically enable waria to be more proactive in searching for HIV and STI-
related information but only 11.2% of respondents ever visited a website or did internet searches
to find information on HIV prevention and transmission. Similarly, only 6.6% of respondents ever
had online communication about the topic, either reading articles/blog/website, chatting or
joining a mailing list. The majority of respondents who visited websites to find information about
HIV and had online communication on the topic came from Surabaya City with a percentage of
20.6% and 15.8% respectively.

Table 4.6 Social Network Sites Frequented by Waria

Most-visited Waria-related websites Frequently-visited Social Network Sites
(%) (%)
District/ Never Follow
n International National Local
Municipality Social
Waria-based Waria- Waria- Other Facebook Twitter Instagram Other
Network
Sites based Sites based Sites
Sites
Aceh Besar# 63 9.5 7.9 4.8 0.0 0.0 0.0 0.0 0.0 0.0

Pematang
249 13.7 24.5 4.4 0.0 1.6 91.2 0.8 0.4 0.4
Siantar City
Palembang City 234 0.4 3.0 15.0 0.0 3.4 68.4 0.9 7.7 1.7

Bandar
134 8.2 10.4 26.9 0.0 1.5 67.9 3.0 21.6 0.7
Lampung City
Tanjung Pinang
54 7.4 3.7 38.9 0.0 0.0 0.0 0.0 0.0 0.0
City #
West Jakarta
224 0.4 1.8 3.6 0.0 1.8 35.3 0.0 0.4 0.9
City
Bogor 250 1.6 16.4 20.4 0.0 1.6 56.0 0.8 2.8 1.2
Purwakarta 250 5.6 5.2 10.4 0.0 6.0 67.6 0.4 1.6 5.6

Bekasi 250 0.0 0.4 3.2 1.2 1.2 83.6 0.0 0.8 0.0

Depok City 200 0.0 3.5 35.5 0.5 1.0 60.0 22.0 8.5 0.0
Banyumas 120 0.0 10.0 44.2 0.0 0.8 87.5 3.3 5.0 0.0

Yogyakarta City 100 6.0 8.0 31.0 0.0 6.0 39.0 7.0 11.0 14.0

Banyuwangi 105 0.0 0.0 0.0 0.0 1.0 75.2 1.9 2.9 2.9

Sumenep 215 16.3 7.0 0.9 0.0 1.9 54.4 0.5 9.3 0.5

Mojokerto City# 24 0.0 0.0 54.2 0.0 0.0 0.0 0.0 0.0 0.0

Madiun City# 22 13.6 4.5 9.1 0.0 0.0 0.0 0.0 0.0 0.0

Surabaya City 209 1.0 0.0 1.4 0.0 2.4 66.5 0.0 13.4 1.9

Kupang City# 15 0.0 46.7 53.3 0.0 0.0 0.0 0.0 0.0 0.0

Pontianak City 220 0.0 0.0 4.1 0.0 1.4 81.4 0.0 2.7 2.7

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 Most-visited Waria-related websites Frequently-visited Social Network Sites
(%) (%)
District/ Never Follow
n International National Local
Municipality Social
Waria-based Waria- Waria- Other Facebook Twitter Instagram Other
Network
Sites based Sites based Sites
Sites

Palangka Raya
43 18.6 11.6 9.3 0.0 0.0 0.0 0.0 0.0 0.0
City #
Ambon City# 72 12.5 9.7 2.8 0.0 0.0 0.0 0.0 0.0 0.0

Aggregate 2760 3.9 6.6 12.5 0.1 2.2 67.1 2.5 5.5 1.9
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Respondents who often visited waria-related websites (23.1%) liked to visit local websites
(12.5%), national waria sites (6.6%) and international waria sites (3.9%). Respondents who
mostly visited local websites were found in Banyumas District (44.2%), while those who
preferred international websites were found in Sumenep District (16.3%) and those who
preferred national waria-related websites were mostly found in Pematang Siantar City (24.5%).

Waria respondents also had an active social network, and only 2.2% did not have social media
presence. As much as 67.1% of waria respondents used Facebook, and the highest proportion
was found in Pematang Siantar City (91.2%). Instagram was another social media application that
waria respondents used. Overall the proportion was 5.5% and the largest proportion at 21.6%
was found in Bandar Lampung City. Twitter was used by only a small proportion of waria (2.2%),
the largest proportion was found in Depok City (22.0%).

4.3 Knowledge about HIV/AIDS, Its Risk, and Prevention

4.3.1 Knowledge about HIV

Being aware and having knowledge about HIV transmission and its prevention method is one
important requirement that respondents need in order to practice behaviors that can protect
them from HIV infection. On the other hand, incorrect understanding and limited knowledge can
become barriers toward adopting protective behaviors. The main objective of HIV prevention
interventions is therefore to ensure that respondents are aware and have the correct knowledge
about HIV/AIDS. This section presents data about respondents’ knowledge on HIV, their risk
perception and knowledge about preventing HIV.

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 Table 4.7 Waria’s Knowledge about HIV and Level of Comprehensive Knowledge

Knowledge about HIV

A Healthy- Prevention Transmission
Have
received looking HIV is not Comprehensive
Individual Reduce HIV Reduce HIV HIV is not
District/Municipality n HIV/AIDS transmitted Knowledge
can be Risk by Risk by Being transmitted
Information through (%)
HIV- Using Faithful to by sharing
(%) mosquito/
Condom Partner food
Infected insect bite
(%) (%) (%)
(%) (%)
Aceh Besar# 63 44.4 47.6 61.9 65.1 34.9 65.1 9.5

Pematang Siantar City 249 83.1 66.3 94.4 94.4 64.7 58.6 36.1

Palembang City 234 95.3 54.3 86.8 85.0 69.7 67.9 35.0

Bandar Lampung City 134 88.1 70.2 88.1 85.1 66.4 67.2 34.3
Tanjung Pinang
54 98.1 33.3 87.0 87.0 88.9 85.2 20.4
City #
West Jakarta City 224 83.0 38.4 56.3 50.9 77.2 75.9 22.8

Bogor 250 89.6 89.6 91.6 76.8 81.2 89.2 60.4

Purwakarta 250 69.6 37.6 49.6 39.2 45.2 60.4 14.0

Bekasi 250 78.4 48.4 78.4 75.2 60.8 59.2 33.6

Depok City 200 77.5 83.0 91.5 87.5 75.5 75.5 59.5

Banyumas 120 86.7 89.2 99.2 97.5 70.8 96.7 69.2

Yogyakarta City 100 94.0 77.0 91.0 89.0 78.0 87.0 56.0

Banyuwangi 105 91.4 35.2 94.3 92.4 88.6 95.2 30.5

Sumenep 215 44.7 39.1 75.4 68.8 65.6 59.1 21.9

Mojokerto City# 24 100.0 50.0 83.3 75.0 91.7 91.7 37.5

Madiun City# 22 95.5 90.9 100.0 100.0 100.0 100.0 90.9

Surabaya City 209 99.0 91.9 93.8 84.2 79.9 83.3 62.2

Kupang City# 15 86.7 93.3 100.0 100.0 100.0 93.3 86.7

Pontianak City 220 90.5 67.7 86.8 82.7 85.5 87.3 55.9

Palangka Raya City# 43 76.7 58.1 72.1 88.4 81.4 76.7 44.2
Ambon City# 72 91.7 56.9 75.0 76.4 76.4 83.3 33.3

Aggregate 2760 82,6 62.4 82.3 77.0 70.9 73.7 40.9

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Comprehensive
knowledge is a composite variable from knowing two prevention methods of sexual transmission of HIV (using condom and reducing
risks of HIV by being faithful with one’s partner), and knowing two misconceptions regarding HIV transmission (HIV is transmitted
through mosquito/insect bite and through sharing food) and knowing that a healthy-looking individual can be infected with HIV.

Respondents’ knowledge about HIV was assessed which included knowledge about prevention
(using condom and being faithful to one’s partner will reduce the risk of HIV infection),
knowledge about misconceptions (mosquito bite can transmit HIV, and so can sharing food with
an infected person), and knowledge that someone who looks healthy can be HIV-infected. Waria
respondents had good knowledge about HIV/AIDS. As much as 82.6% of respondents had
received information on HIV/AIDS and as an aggregate 62.4% of respondents stated that people
who look healthy can be HIV-infected. The proportion however varied significantly between
districts, and in some survey sites (West Jakarta City, and Purwakarta, Banyuwangi and Sumenep

69
 Districts), less than 40% of respondents knew that information. As much as 77.0% of respondents
knew that being faithful to one’s partner can reduce the risk of HIV infection, while 82.3% knew
about condom use to reduce risks. This shows that more than 75% of respondents knew about
HIV prevention methods, except in two Districts/Municipalities (Purwakarta District and West
Jakarta City) where less than 75% respondents had this knowledge.

Regarding misconceptions about HIV transmission, overall 70.9% of respondents knew that
mosquito/insect bites do not transmit HIV and 73.7% knew that sharing food with an HIV-
infected person do not transmit HIV. In Purwakarta District however, correct knowledge about
misconception was only 45.2%. Adequate knowledge about HIV/AIDS is an effective way to
prevent risk behavior and practices, so a lot of prevention programs focus on improving
knowledge on HIV transmission. The hope is to prevent risk behavior and reduce stigma against
people who live with HIV/AIDS (PLHIV). Stigma has been proven to be highly influenced by lack
of knowledge and misconceptions about HIV transmission (Nubed, 2016).
Respondents’ level of comprehensive knowledge on HIV/AIDS was assessed through 5 questions
that consisted of 2 questions on prevention method, 2 questions on misconceptions and a
question about whether or not a healthy-looking individual can be HIV-infected. To be
categorized as having comprehensive knowledge, respondents would need to respond correctly
to all five questions. As an aggregate, only 40.9% of respondents had comprehensive knowledge
while at the level of individual district, only 6 Districts/Municipalities had more than 50%
respondents with comprehensive knowledge.

4.3.2 Risk Perception and Knowledge about Prevention Method

Perception is essentially a cognitive process that every person experiences in order to understand
their environment, and they do that through their sense of sight, hearing, touch, feeling, and smell.
Different people may perceive the same object differently, and a person’s perception is influenced
by factors such as knowledge, level of education, sight, smell, hearing and past experiences
(Thoha, 2010).

Table 4.8 HIV Risk Perception and Protective Behavior Adopted by Waria

Protective Behavior to Prevent HIV Infection

Risk Perception
District/Municipality n Always use Be faithful to sex Not share used injection
(%)
condom (%) partner (%) needles (%)
Aceh Besar# 63 7.9 63.5 50.8 31.8
Pematang Siantar City 249 83.1 92.4 82.7 68.3
Palembang City 234 73.5 85.0 70.9 59.8
Bandar Lampung City 134 70.9 91.8 73.1 50.8

Tanjung Pinang City# 54 85.2 92.6 53.7 31.5

West Jakarta City 224 83.9 79.0 67.4 13.4

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 Protective Behavior to Prevent HIV Infection
Risk Perception
District/Municipality n Always use Be faithful to sex Not share used injection
(%)
condom (%) partner (%) needles (%)
Bogor 250 86.4 92.0 33.2 33.6

Purwakarta 250 59.6 79.6 39.2 23.6

Bekasi 250 66.0 79.2 76.8 54.0

Depok City 200 85.5 92.0 44.0 7.5

Banyumas 120 97.5 100.0 86.7 87.5

Yogyakarta City 100 75.0 94.0 56.0 45.0

Banyuwangi 105 90.5 98.1 91.4 77.1

Sumenep 215 42.3 74.9 59.1 42.8

Mojokerto City# 24 87.5 91.7 75.0 75.0

Madiun City# 22 77.3 86.4 72.7 68.2

Surabaya City 209 91.9 94.7 63.6 57.4

Kupang City# 15 93.3 100.0 60.0 66.7

Pontianak City 220 26.7 94.1 81.4 67.3

Palangka Raya City# 43 95.3 86.1 55.8 37.2

Ambon City# 72 51.4 84.7 63.9 29.2

Aggregate 2760 74.8 87.8 64.4 46.8

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

A perception of being at risk of HIV infection is one requirement to make respondents be aware
about risk behaviors and correlate HIV transmission to their own behavior. Aggregate data
showed that 74.8% of waria respondents perceived themselves to be at risk of getting HIV, which
the majority stated was because they have had unprotected sex (94.1%). Location-wise, all the
respondents (100%) in Banyumas District perceived themselves to be at risk since they all have
had unprotected sex.

In the 2018-2019 IBBS respondents were also asked about their knowledge on HIV prevention.
Overall, 87.8% of respondents stated consistent use of condom as a way to prevent HIV infection.
Being faithful to one’s sex partner was mentioned by 64.6% respondents, while 46.8% mentioned
about not sharing non-sterile needles. The highest percentage of respondents who mentioned
about condom was found in Banyumas District (100%) and the lowest percentage was found in
Sumenep District (74.9%).

4.4 Condom and Sexual Behavior

4.4.1 Access to Condom

Use of condom in risky sexual intercourse is one prevention method of HIV. Condom can be highly
effective in preventing sexual transmission of HIV, provided they are used consistently and
correctly. Research shows that condoms are impermeable to HIV. It acts as a barrier to prevent

71
the HIV virus or STI-causing bacteria in blood, semen or vaginal fluid from being transferred from
one person to another during sex. Without condom, viruses or bacteria can move from an infected
partner to an uninfected partner. Condoms however can fail to prevent transmission if they leak
or break during sex (Catie, 2018). From the total survey respondents 97.4% of them knew about
condom, but then there was still 2.6% of respondents who did not know about condom. In the
survey, questions that related to condom were only asked to respondents who knew about
condom.

Table 4.9 Ways Waria Obtained Condom in the Last Month

Access to Condom in the Last Month (%)

District/Municipality n*
Bought and Got
Did not have condom Bought Condom Got Free Condom
Free Condom
Aceh Besar# 60 23.3 46.7 11.7 18.3

Pematang Siantar City 247 15.0 44.1 21.9 19.0

Palembang City 233 7.7 2.1 76.4 13.7

Bandar Lampung City 133 10.5 8.3 69.2 12.0

Tanjung Pinang City# 54 9.3 3.7 57.4 29.6

West Jakarta City 205 3.4 13.7 73.7 9.3

Bogor 247 6.5 3.6 58.3 31.6

Purwakarta 236 16.9 12.7 66.1 4.2

Bekasi 238 13.0 5.0 73.5 8.4

Depok City 198 3.5 9.1 63.1 24.2

Banyumas 120 22.5 7.5 50.0 20.0

Yogyakarta City 100 7.0 7.0 81.0 5.0

Banyuwangi 105 6.7 1.0 84.8 7.6

Sumenep 204 42.2 2.9 39.2 15.7

Mojokerto City# 24 4.2 12.5 50.0 33.3

Madiun City# 22 4.5 9.1 77.3 9.1

Surabaya City 209 4.3 6.2 82.8 6.7

Kupang City# 13 7.7 0.0 69.2 23.1

Pontianak City 214 10.7 8.9 39.7 40.7

Palangka Raya City# 43 14.0 0.0 51.2 34.9

Ambon City# 72 18.1 0.0 66.7 15.3

Aggregate 2689 12.2 10.3 61.1 16.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples: *The number of
waria who knew about condom

Each respondent had their own way of obtaining condom in the last month, while 12.2%
respondents did not have condom in the last month. Most waria respondents had access to free
condoms (61.1%). Only 10.3% of respondents bought condom, and 16.4% of respondents either
bought or got free condoms. This shows that quite a number of respondents still relied on free

72
 condoms, partly because of the stigma around condom purchase that is still associated with free
sex (Eda, 2012).

Location-wise, the majority of respondents who received free condom was found in Banyuwangi
District (84.8%) and Surabaya City (82.8%). Respondents who bought condoms were mostly
found in Pematang Siantar City (44.1%), while respondents who did not have condom in the last
month were mostly found in Sumenep District (42.2%).

Table 4.10 Places that Provide Free Condom for Waria

Places that Provide Free Condom (%)

District/Municipality n* Health Outreach Condom
Facility Friends Client Pimp NGO Other
Worker Outlet
Aceh Besar# 46 17.4 58.7 0.0 4.3 15.2 4.3 0.0 0.0

Pematang Siantar City 101 3.0 32.7 0.0 0.0 44.6 2.0 16.8 1.0

Palembang City 215 1.4 11.6 0.0 0.0 41.4 37.2 8.4 0.0

Bandar Lampung City 108 10.2 21.3 0.0 0.0 28.7 30.6 9.3 0.0

Tanjung Pinang City# 47 19.1 17.0 0.0 0.0 29.8 27.7 6.4 0.0

West Jakarta City 170 7.6 6.5 1.2 0.0 81.2 3.5 0.0 0.0

Bogor 226 0.9 20.8 0.4 0.0 41.2 36.3 0.0 0.4

Purwakarta 172 19.8 31.4 0.0 0.6 33.7 13.4 1.2 0.0

Bekasi 198 0.0 22.2 0.0 3.5 24.2 44.4 5.6 0.0

Depok City 173 1.2 19.7 1.2 0.0 74.0 2.9 1.2 0.0

Banyumas 84 1.2 11.9 0.0 0.0 11.9 72.6 2.4 0.0

Yogyakarta City 88 3.4 8.0 0.0 0.0 76.1 11.4 0.0 1.1

Banyuwangi 97 1.0 4.1 0.0 0.0 14.4 80.4 0.0 0.0

Sumenep 112 29.5 55.4 5.4 2.7 5.4 0.9 0.0 0.9

Mojokerto City# 20 35.0 45.0 0.0 0.0 10.0 10.0 0.0 0.0

Madiun City# 19 36.8 0.0 0.0 0.0 10.5 52.6 0.0 0.0

Surabaya City 187 6.4 5.9 0.0 0.0 54.5 33.2 0.0 0.0

Kupang City# 12 0.0 8.3 0.0 0.0 41.7 8.3 41.7 0.0

Pontianak City 172 1.7 4.7 5.8 0.0 9.3 62.2 16.3 0.0

Palangka Raya City# 37 0.0 13.5 0.0 0.0 16.2 67.6 0.0 2.7

Ambon City# 59 8.5 1.7 0.0 0.0 49.2 39.0 1.7 0.0

Aggregate 2103 5.8 17.7 1.0 0.5 40.2 30.3 4.3 0.2
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of waria
who had access to free condom and both ‘bought and got free condom’.

The question about places that provide free condoms was only asked to respondents who
received free condoms or bought condoms as well as received free ones. In the aggregate analysis,
the majority of free condoms were available from NGOs (40.2%) and outreach workers (30.3%).
The highest percentage of respondents who received free condoms from NGOs was recorded in
West Jakarta (81.2%) followed by Yogyakarta City (76.1%), while free condoms from outreach
workers were mostly found in Banyuwangi District (80.4%). Only a small percentage of

73
 respondents received free condoms from health facilities (5.8%). There were also 17.7%
respondents who obtained free condoms from their friends.

The next variable that the survey explored was related to the brand of condom, respondents’
experience with leakage and use of lubricant. Questions about condom’s brand and use of
lubricant were only asked to respondents who knew about condom, while questions about leaked
condom were only asked to respondents who had condom in the last month.

Table 4.11 Condom Brand, Condom Breakage and Use of Lubricant by Waria

Brand of Condom (%) Torn or

Use of
Leaked
District/Municipality n* BKKBN/ Pleasure Lubricant
Sutra Fiesta Durex Artika Other Condom**
FP Plus (%)
(%)
Aceh Besar# 60 73.3 16.7 6.7 0.0 0.0 3.3 0.0 53.3 25.6

Pematang Siantar City 247 93.5 2.0 1.2 0.8 0.0 0.0 2.4 83.0 5.9

Palembang City 233 62.7 4.7 1.7 1.7 1.7 26.6 0.9 74.7 10.3

Bandar Lampung City 133 93.2 2.3 1.5 0.0 0.0 0.0 3.0 80.5 23.5

Tanjung Pinang City# 54 96.3 1.9 0.0 0.0 1.9 0.0 0.0 90.7 22.2

West Jakarta City 205 57.6 17.6 22.9 2.0 0.0 0.0 0.0 64.9 19.4

Bogor 247 95.5 2.8 1.2 0.0 0.0 0.0 0.4 91.1 8.1

Purwakarta 236 94.5 2.1 1.3 0.0 0.0 0.4 1.7 67.8 17.9

Bekasi 238 91.2 3.8 2.1 1.3 0.8 0.0 0.8 84.9 30.9

Depok City 198 85.4 11.1 3.5 0.0 0.0 0.0 0.0 92.9 11.3

Banyumas 120 79.2 5.8 0.0 0.0 0.0 14.2 0.8 90.0 2.4

Yogyakarta City 100 81.0 10.0 1.0 0.0 1.0 0.0 7.0 88.0 10.0

Banyuwangi 105 90.5 0.0 0.0 0.0 0.0 7.6 1.9 97.1 1.1

Sumenep 204 75.0 2.5 3.4 19.1 0.0 0.0 0.0 56.9 9.0

Mojokerto City# 24 95.8 0.0 0.0 0.0 0.0 0.0 4.2 83.3 18.2

Madiun City# 22 95.5 0.0 4.5 0.0 0.0 0.0 0.0 90.9 5.3

Surabaya City 209 99.5 0.0 0.0 0.0 0.0 0.0 0.5 95.2 24.6

Kupang City# 13 92.3 7.7 0.0 0.0 0.0 0.0 0.0 92.3 16.7

Pontianak City 214 90.7 4.2 0.0 0.0 0.0 0.5 4.7 81.3 2.6

Palangka Raya City# 43 83.7 2.3 9.3 4.7 0.0 0.0 0.0 67.4 17.6

Ambon City# 72 88.9 1.4 0.0 0.0 0.0 0.0 9.7 63.9 26.9

Aggregate 2689 85.2 4.8 3.0 1.9 0.3 3.3 1.5 81.0 13.4
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of waria
who knew about condom; **Among respondents who had condom in the last month

Information about condom’s brand is useful to find out about the type of condom that waria
respondents often use, in relation to provision of free condom. The hope is that free condoms
would be better accepted by respondents if they were the type that respondents often used. Based
on aggregate data, the majority of respondents used the sutra brand of condom (85.2%) and only
a small percentage used fiesta (4.8%), durex (3.0%) and pleasure plus (3.3%).

74
 Waria are one key population who engage in high-risk anal sex. Condom breakage as a result of
friction during sex is quite likely, resulting in an increased risk of STI or HIV infection. Use of
water-based lubricant can reduce friction and help prevent condom breakage during sex so all
waria are expected to use condom in anal sex. All respondents were asked whether they ever had
any experience with leaked condom and whether they used lubricant during sex. The aggregate
data showed that 13.4% of respondents did experience leaked condom, the highest percentage
was found in Bekasi District (30.9%). The majority of respondents used lubricant (81.0%) and in
5 Districts/Municipalities the use of lubricant was above 90% (Bogor District, Depok City,
Banyumas District, Banyuwangi District, and Surabaya City).

4.4.2 Sexual Behavior and Condom Use

Sex behavior and condom use among waria was divided based on the type of sex partners, i.e.
steady and non-steady male sex partner through selling or buying sex. Studies have demonstrated
that the type of partner (steady, non-steady partner, and commercial sex partner) influenced the
sex behavior of key populations who are at high-risk of HIV infection. Type of sex partners had
also been reported as an important predictor of unprotected sex (Wilson, 2010).

This section presents the sexual behavior and condom use among waria that included the age at
first sexual intercourse, condom use during the last sexual encounter, sex in the last month,
number of partners and condom use consistency with steady and non-steady male partner,
during selling and buying sex.

4.4.2.1 Age at First Sexual Intercourse

The average age respondents first had sexual intercourse is an important indicator of high-risk
sexual behavior and can be used as a proxy for HIV infection. Early sexual debut is correlated with
increased risk behavior such as having multiple partners, decreased condom use and increased
sexually-transmitted infection (Wand & Ramjee, 2012).

Table 4.12 Age of First Vaginal and and Anal Sex among Waria

Age at First Vaginal Sex (%) Age at First Anal Sex (%)
District/
n* n**
Municipality ≤14 15-17 18-24 ≥ 25 Don’t ≤14 15-17 18-24 ≥ 25 Don’t
Median Median
years years years years remember years years years years remember
Aceh Besar# 18 20 0.0 0.0 22.2 11.1 66.7 62 18 1.6 11.3 17.7 3.2 66.1

Pematang Siantar 10.9 30.9 38.2 14.5 5.5 21.0 37.0 32.1 4.5 5.3
55 18 243 17
City
Palembang City 66 21 1.5 4.5 24.2 16.7 53.0 229 17 7.9 32.3 33.2 2.2 24.5

Bandar Lampung 3.4 17.2 41.4 27.6 10.3 10.8 31.5 42.3 7.7 7.7
29 20 130 18
City
Tanjung Pinang 0.0 34.4 31.3 3.1 31.3 1.9 39.6 37.7 3.8 17.0
32 18 53 18
City #
West Jakarta City 104 19 2.9 8.7 31.7 3.8 52.9 212 20 3.8 20.3 53.8 17.9 4.2

Bogor 22 17 9.1 36.4 18.2 4.5 31.8 245 16 5.3 59.6 18.0 0.4 16.7

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 Age at First Vaginal Sex (%) Age at First Anal Sex (%)
District/
n* n**
Municipality ≤14 15-17 18-24 ≥ 25 Don’t ≤14 15-17 18-24 ≥ 25 Don’t
Median Median
years years years years remember years years years years remember
Purwakarta 78 20 1.3 20.5 35.9 17.9 24.4 238 18 12.2 26.9 40.8 10.1 10.1

Bekasi 40 18 2.5 27.5 32.5 12.5 25.0 246 18 2.4 16.7 40.2 4.5 36.2

Depok City 21 21 0.0 4.8 9.5 0.0 85.7 187 20 0.0 7.0 35.8 5.9 51.3

Banyumas 57 19 7.0 22.8 45.6 12.3 12.3 120 17 6.7 45.0 41.7 5.8 0.8

Yogyakarta City 10 17 40.0 10.0 30.0 20.0 0.0 97 17 24.7 36.1 26.8 10.3 2.1

Banyuwangi 21 21 0.0 19.0 42.9 9.5 28.6 105 16 22.9 29.5 18.1 4.8 24.8

Sumenep 61 18 0.0 14.8 14.8 1.6 68.9 212 20 2.8 13.7 31.6 5.7 46.2

Mojokerto City# 5 16 20.0 0.0 0.0 20.0 60.0 23 18 21.7 21.7 34.8 17.4 4.3

Madiun City# 8 15 0.0 75.0 25.0 0.0 0.0 20 18 15.0 25.0 50.0 5.0 5.0

Surabaya City 33 22 0.0 15.2 51.5 33.3 0.0 208 18 12.0 31.7 45.7 10.6 0.0

Kupang City# 8 16 0.0 12.5 0.0 0.0 87.5 11 17 18.2 45.5 18.2 9.1 9.1

Pontianak City 25 19 4.0 4.0 40.0 4.0 48.0 207 19 3.4 9.2 42.5 4.3 40.6

Palangka Raya 0.0 33.3 14.8 0.0 51.9 4.7 32.6 20.9 0.0 41.9
27 17 43 17
City#
Ambon City# 43 18 9.3 11.6 30.2 7.0 41.9 70 17 17.1 34.3 38.6 2.9 7.1

Aggregate 622 19 3.9 16.6 32.6 12.1 34.9 2679 18 8.7 27.8 36.4 6.6 20.5
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of waria
who ever engaged in vaginal sex; **Number of waria who ever engaged in anal sex.

From a total of 2760 waria respondents, 622 of them have had vaginal sex, and the median age of
first vaginal sex was 19 years. A younger median age (17 years old) was found in Bogor District
and Yogyakarta City and an older median age (22 years old) was found in Surabaya City. The
majority of respondents (32.6%) had their first vaginal sex between the age of 18 to 24 years. The
largest proportion was found in Surabaya City (51.5%). Some respondents (16.6%) had their first
vaginal sex at a very young age, between 15 to 17 years, and the majority of them was found in
Bogor District (36.4%). Some respondents (12.1%) were older than 25 years when they first had
vaginal sex and the largest proportion was found in Surabaya City (33.3%). The survey also found
that 3.9% of respondents had their first vaginal sex before the age of 14, and the largest
proportion was in Yogyakarta City. Not all districts had this very young sexually-active waria
population, for example they were not found in Depok City, Banyuwangi and Sumenep Districts
or Surabaya City.
A total of 2679 waria respondents also engaged in anal sex, and the median age of first anal sex
was 18 years. A younger median age of 16 was found in Bogor and Banyuwangi Districts, while
an older median age (20 years old) was detected in West Jakarta, Depok City and Sumenep
District. Overall 36.4% of respondents had their first anal sex between age 18-24 years and the
largest proportion was in West Jakarta (53.8%). A slightly lower percentage (27.8%) started anal
sex as teenagers (15-17 years) with the majority residing in Bogor District (59.6%). A smaller
proportion of waria (6.6%) started anal sex older than 25 years of age, and the majority was found
in West Jakarta (17.9%). Similar to vaginal sex, there were also some respondents (8.7%) who

76
 had their first anal sex at a very young age, below 14 years old, and the majority (24.7%) was also
found in Yogyakarta City. These waria who had been sexually-active since a very young age were
found in all survey sites except Depok City.

Table 4.13 Age Waria Respondents Started Buying and Selling Sex

Age at First Time Buying Sex (%) Age at First Time Selling Sex (%)
District/Municipality n* ≤14 15-17 18-24 ≥ 25 n** ≤14 15-17 18-24 ≥ 25
Median Median
years years years years years years years years
Aceh Besar# 15 25 0.0 0.0 46.7 53.3 35 20 0.0 14.3 65.7 20.0

Pematang Siantar City 37 23 2.7 13.5 37.8 45.9 212 18 2.8 28.3 58.5 10.4

Palembang City 37 22 0.0 8.1 54.1 37.8 109 19 0.9 28.4 62.4 8.3

Bandar Lampung City 31 21 0.0 12.9 61.3 25.8 107 19 6.5 24.3 52.3 16.8

Tanjung Pinang
22 20 0.0 40.9 50.0 9.1 36 20 0.0 33.3 58.3 8.3
City #
West Jakarta City 21 24 4.8 9.5 38.1 47.6 31 21 6.5 16.1 41.9 35.5
Bogor 19 23 0.0 0.0 52.6 47.4 172 18 3.5 40.1 54.1 2.3
Purwakarta 44 25 0.0 13.6 36.4 50.0 150 20 4.7 17.3 58.7 19.3
Bekasi 40 25 0.0 0.0 32.5 67.5 141 20 2.1 9.9 70.9 17.0
Depok City 54 20 0.0 0.0 59.3 40.7 99 20 0.0 4.0 74.7 21.2
Banyumas 13 22 0.0 0.0 69.2 30.8 68 21 1.5 25.0 52.9 20.6
Yogyakarta City 30 30 0.0 6.7 20.0 73.3 85 18 10.6 36.5 32.9 20.0
Banyuwangi 37 25 5.4 10.8 29.7 54.1 78 19 1.3 35.9 47.4 15.4
Sumenep 58 23 0.0 15.5 51.7 32.8 88 21 3.4 10.2 65.9 20.5
Mojokerto City# 4 25 0.0 0.0 50.0 50.0 17 20 0.0 17.6 52.9 29.4
Madiun City# 2 21 0.0 0.0 100.0 0.0 13 20 7.7 7.7 69.2 15.4
Surabaya City 16 30 0.0 6.3 12.5 81.3 140 20 4.3 23.6 47.9 24.3
Kupang City# 9 20 0.0 22.2 66.7 11.1 14 18 0.0 42.9 50.0 7.1
Pontianak City 2 26 0.0 0.0 50.0 50.0 122 19 0.8 12.3 74.6 12.3
Kota Palangka
2 22 0.0 50.0 0.0 50.0 32 18 9.4 25.0 62.5 3.1
Raya#
Ambon City# 19 20 5.3 26.3 42.1 26.3 42 19 14.3 19.0 52.4 14.3
Aggregate 439 24 0.9 8.1 43.4 47.4 1602 19 3.3 23.0 58.2 15.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of waria
who ever buy sex; **Number of waria who ever sell sex.

From 2760 waria respondents, 439 had bought sex. The median age when waria started buying
sex was 24 years old, younger in Depok City (20 years) and older in Surabaya and Yogyakarta
Cities (30 years old). The majority started buying sex when they were older than 25 (47.4%), and
the largest proportion was in Surabaya City (81.3%). Respondents also sold sex, overall 43.4% of
them started between the age of 18 to 24. The largest proportion who started selling sex at this
age was in Banyumas District (69.2%). Some respondents (8.1%) started as teenagers, at 15-17
years, and the majority was found in Sumenep District (15.5%). A small proportion (0.9%) of
respondents were younger than 14 years old when they started buying sex, and the largest

77
 proportion was found in Banyuwangi District (5.4%). This young group was found in two other
sites, i.e. West Jakarta (4.8%) and Pematang Siantar City (2.7%) but not in the other survey sites.

In this survey 1602 waria respondents had sold sex to men and the median age they started
selling sex was 19 years old. Bogor District, Pematang Siantar and Yogyakarta Cities had a
younger median age (18 years), while West Jakarta, Banyumas and Sumenep Districts had an
older median age (21 years). More than half of respondents (58.2%) started selling sex in the 18-
to 24-year age range, and the largest proportion was found in Depok City (74.7%). Almost a
quarter (23.0%) started selling sex as teenagers between 15 to 17 years and the majority resided
in Bogor District (40.1%). The largest proportion of waria respondents who started selling sex
older than 25 years old was found in West Jakarta (35.5%) while as an aggregate the percentage
was 15.5%. Some respondents (3.3%) also started selling sex before their 14th birthday and the
largest proportion was found in Yogyakarta City (10.6%).

4.4.2.2 Sexual Behavior with Steady Male Partners

A steady male partner is a sex partner who respondents acknowledged or considered as a willing
sex partner in a committed relationship that has lasted for at least 3 months.

Based on the aggregate data, 39.2% of waria respondents had a steady male partner. The highest
proportion was found in Banyumas District (63.3%) and the lowest was in Sumenep District
(20.5%).

Table 4.14 Sexual Behavior of Waria with Steady Male Partner

Used condom Had sex with a Average number of Consistently use

Had a steady during last sex
steady partner steady male condom with a
District/Municipality n male partner with a steady
in the last partners in the last steady partner**
(%) partner*
month* (%) month** (%) (%)
(%)
Aceh Besar# 63 20.6 100.0 92.3 5 83.3

Pematang Siantar City 249 30.1 46.7 100.0 2 32.0

Palembang City 234 32.5 63.2 92.1 2 44.3

Bandar Lampung City 134 48.5 66.2 98.5 2 60.9

Tanjung Pinang
54 55.6 96.7 100.0 3 73.3
City #
West Jakarta City 224 37.5 66.7 100.0 3 27.4

Bogor 250 45.6 88.6 97.4 2 78.4

Purwakarta 250 42.0 66.7 99.0 3 45.2

Bekasi 250 30.4 63.2 100.0 2 51.3

Depok City 200 33.5 97.0 98.5 2 83.3

Banyumas 120 63.3 48.7 96.1 2 45.2

Yogyakarta City 100 31.0 71.0 96.8 2 70.0

Banyuwangi 105 47.6 54.0 96.0 2 50.0

78
 Used condom Had sex with a Average number of Consistently use
Had a steady during last sex
steady partner steady male condom with a
District/Municipality n male partner with a steady
in the last partners in the last steady partner**
(%) partner*
month* (%) month** (%) (%)
(%)
Sumenep 215 20.5 13.6 95.5 3 11.9

Mojokerto City# 24 70.8 70.6 100.0 2 64.7

Madiun City# 22 31.8 71.4 100.0 2 71.4

Surabaya City 209 46.9 85.7 100.0 2 74.5

Kupang City# 15 26.7 50.0 100.0 3 0.0

Pontianak City 220 55.0 86.0 98.3 2 78.2

Palangka Raya City# 43 34.9 33.3 100.0 2 13.3

Ambon City# 72 45.8 69.7 100.0 3 45.5

Aggregate 2760 39.2 68.9 97.9 2 56.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who had a steady male sex partner; **Among respondents who had sex in the last month

As an aggregate, from all respondents who had a steady male partner, 97.9% had sex in the last
month and 68.9% used condom in their last sexual encounter. Condom use during the last sex
was highest in Depok City (97.0%), showing a high level of awareness about HIV and STI
prevention. Not all sites had this high level of awareness, for example in in Sumenep District,
condom use in the last sex was still very low (13.6%).

The survey also gathered information about consistent condom use as one effort to prevent HIV
transmission. Respondents were asked about their condom use during sex in the last month, and
consistent use was defined as often or always using condom. In all survey sites, 97.9% of
respondents had sex with their steady partner. On average each respondent had two steady
partners. Condom was consistently used only by 56.0% of respondents, indicating that a lot of
respondents were actually at risk of getting HIV/STI due to inconsistent condom use.

Consistent condom use also varied greatly between sites. Only 5 sites had more than 70%
respondents who used condom consistently (Bogor District, Depok, Yogyakarta, Surabaya and
Pontianak Cities). Sumenep District had the lowest proportion of consistent condom use.

Table 4.15 Sexual Behavior of Waria with Non-Steady Male Partner

Had sex with a Average number of

Had a non- Used condom Consistently use
non-steady non-steady male
steady male during last sex condom with a
District/Municipality n partner in the last partners in the last
partner with a non-steady non-steady
(%) month* month**
partner * (%) partner** (%)
(%) (%)
Aceh Besar# 63 23.8 100.0 86.7 8 69.2

Pematang Siantar City 249 70.3 68.0 93.1 8 41.1

Palembang City 234 52.6 61.0 80.5 6 57.6

Bandar Lampung City 134 62.7 83.3 81.0 7 75.0

Tanjung Pinang City# 54 57.4 93.5 93.5 2 62.1

79
 Had sex with a Average number of
Had a non- Used condom Consistently use
non-steady non-steady male
steady male during last sex condom with a
District/Municipality n partner in the last partners in the last
partner with a non-steady non-steady
(%) month* month**
partner * (%) partner** (%)
(%) (%)
West Jakarta City 224 23.2 61.5 71.2 3 35.1

Bogor 250 74.4 93.5 97.3 11 82.9

Purwakarta 250 54.0 77.0 79.3 10 50.5

Bekasi 250 68.4 68.4 88.3 3 60.3

Depok City 200 69.0 74.6 90.6 5 52.8

Banyumas 120 61.7 68.9 78.4 4 67.2

Yogyakarta City 100 62.0 83.9 79.0 12 83.7

Banyuwangi 105 66.7 62.9 82.9 6 50.0

Sumenep 215 35.3 7.9 82.9 6 3.2

Mojokerto City# 24 58.3 92.9 64.3 12 88.9

Madiun City# 22 36.4 87.5 62.5 10 80.0

Surabaya City 209 86.1 92.8 93.9 11 84.6

Kupang City# 15 60.0 77.8 77.8 2 0.0

Pontianak City 220 47.7 98.1 91.4 9 97.9

Palangka Raya City# 43 51.2 59.1 81.8 8 27.8

Ambon City# 72 51.4 54.1 62.2 6 43.5

Aggregate 2760 59.1 74.6 87.3 8 63.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents with non-steady male sex partner; **Among respondents who had sex in the last month

In this survey, a non-steady male partner is defined as a male (not waria) partner who does not
receive or give payment (monetary or non-monetary) for sex, and is not the respondent’s regular
sex partner. This partner can also be referred to as “non-commercial” partner. As an aggregate,
59.1% of respondents had a non-steady male partner, with the majority residing in Surabaya City
(86.1%). The lowest proportion was found in West Jakarta (23.2%). Condom use with a non-
steady partner was quite high, at 74.6%, and in some sites the percentage even reached above
90%, i.e. in Bogor District (93.5%), Surabaya City (92.8%) and Pontianak City (98.1%).

Among respondents with a non-steady male partner, 87.3% of them had sex in the last month.
The highest proportion was in Bogor District (97.3%), and Surabaya City (93.9%). On average
respondents had 8 non-steady partners in a month, so partner exchange was quite frequent.
Waria was one group who is most at-risk of transmitting and getting HIV as waria engaged in anal
sex. The anus has a mucosal epithelium that is relatively thin and prone to injury as the anus does
not have natural lubricant like the vagina. Injury to the anal area can give HIV easier access to the
bloodstream (Ningtiyas, 2016) which is why condom use is very important.

Overall, condom use with a non-steady partner was not very high either (63.0%) and in some
areas was actually very low (Banyumas District and West Jakarta). A high level of consistent
condom use was found in Pontianak City (97.9%).

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 Table 4.16 Sexual Behavior of Waria who Buy Sex from Men

Used condom
Bought sex in Average number Consistently use
Buy Sex from when bought sex
District/Municipality n the last month* of partners in the condom when
Men (%) last time*
(%) last month** (%) buying sex**(%)
(%)
Aceh Besar# 63 23.8 86.7 33.3 9 60.0

Pematang Siantar City 249 14.9 62.2 24.3 2 55.6

Palembang City 234 16.2 63.2 42.1 3 31.3

Bandar Lampung City 134 23.1 74.2 38.7 3 41.7

Tanjung Pinang City# 54 40.7 95.5 77.3 2 52.9

West Jakarta City 224 9.4 57.1 42.9 2 55.6

Bogor 250 7.6 89.5 31.6 1 66.7

Purwakarta 250 18.4 73.9 41.3 1 52.6

Bekasi 250 17.2 67.4 44.2 2 42.1

Depok City 200 27.5 52.7 76.4 6 47.6

Banyumas 120 10.8 30.8 7.7 1 100.0

Yogyakarta City 100 30.0 73.3 13.3 1 75.0

Banyuwangi 105 35.2 48.6 43.2 2 25.0

Sumenep 215 27.0 22.4 27.6 4 37.5

Mojokerto City# 24 16.7 75.0 50.0 1 50.0

Madiun City# 22 9.1 100.0 50.0 3 100.0

Surabaya City 209 7.7 81.3 25.0 2 100.0

Kupang City# 15 60.0 88.9 11.1 3 0.0

Pontianak City 220 0.9 100.0 50.0 15 100.0

Palangka Raya City# 43 4.7 50.0 0.0 0 0.0

Ambon City# 72 26.4 63.2 57.9 3 45.5

Aggregate 2760 16.2 59.0 39.0 3 46.6
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among respondents
who buy sex from men. **Among respondents who bought sex in the last month

In addition to having sex with a steady and non-steady male partner, waria respondents were
also involved in commercial sex. The survey tried to gather information about the sexual behavior
of respondents toward men (not waria and not their steady partner) during paid sex that involved
monetary or non-monetary payment. In this case, the respondents acted as clients. As an
aggregate, 16.2% of respondents bought sex from men. The largest proportion was found in
Banyuwangi District (35.2%).

Overall, only about half of respondents (59.0%) used condom in their last paid sex, but the
percentage varied greatly between sites, from 100% in Pontianak City to only 22.4% in Sumenep
District. This shows that respondents’ level of awareness about STI and HIV prevention was still
low.

81
 From all the respondents who had bought sex, 39.0% bought sex in the last month. The proportion
ranged from 76.4% in Depok City to 7.7% in Banyumas District. On average respondents had sex
with 3 different partners in the last month, except in Pontianak City where the average number
of sex partners was very high, i.e. 15. This put respondents at much higher risk for HIV and STI
transmission. Condom was also not consistently used and only 46.6% of respondents did so when
they bought sex in the last month. A large variation existed between sites, from 100% in
Banyumas District, Surabaya and Pontianak Cities to as low as 25.0% in Banyuwangi District. Yet,
correct and consistent use of condom can reduce the risk for HIV and STI transmission in high-
risk sexual activity such as buying and selling sex.

Table 4.17 Sexual Behavior of Waria who Sell Sex to Men

Average number of Consistently use

Sell sex to Sold sex in the last
District/Municipality n clients in the last condom when selling
men (%) month* (%)
month** (%) sex**(%)
Aceh Besar# 63 60.3 73.7 8 75.0

Pematang Siantar City 249 85.5 83.1 10 37.3

Palembang City 234 47.4 54.1 11 53.3

Bandar Lampung City 134 79.9 77.6 10 74.7

Tanjung Pinang City# 54 74.1 85.0 3 70.6

West Jakarta City 224 14.7 78.8 4 50.0

Bogor 250 71.6 93.9 13 81.5

Purwakarta 250 62.0 56.8 17 47.7

Bekasi 250 62.0 78.1 4 63.6

Depok City 200 53.0 80.2 7 36.5

Banyumas 120 56.7 76.5 12 71.2

Yogyakarta City 100 85.0 62.4 22 86.8

Banyuwangi 105 74.3 71.8 8 66.1

Sumenep 215 40.9 56.8 10 2.0

Mojokerto City# 24 70.8 70.6 6 83.3

Madiun City# 22 59.1 92.3 7 100.0

Surabaya City 209 67.0 84.3 10 81.4

Kupang City# 15 93.3 57.1 3 25.0

Pontianak City 220 55.5 78.7 12 99.0

Palangka Raya City# 43 74.4 50.0 11 31.3

Ambon City# 72 58.3 64.3 4 51.9

Aggregate 2760 59.4 75.2 9 62.6

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who sell sex to men. **Among respondents who sold sex in the last month.

Selling sex was included as a variable in the survey to get information about respondent’s sexual
behavior in the last year when respondents sold sex to men (not waria and not their steady
partner) and received monetary or non-monetary payment. In other words, the respondents

82
 acted as sex workers, and provided sexual service to men who were their client/customer. From
the aggregate data, 59.4% of waria respondents stated that they sold sex to men. The highest
proportion was found in Pematang Siantar City (85.5%) and Yogyakarta City (85.0%).

Among the respondents who had sold sex, 75.1% did so in the last month. In all sites, the
percentage who did so was above 50%, and the highest was 93.9% in Bogor City. The lowest
proportion was 54.1% in Palembang City. On average respondents provided sex service to 9
clients in the last month. Condom use consistency while selling sex was only 62.6%. The highest
was found in Pontianak (99.0%) and Yogyakarta Cities (86.8%), but in Sumenep District the
percentage was very low. Faulina (2012) reported that waria do not consistently use condom
during sex with a client because clients feel uncomfortable when condom is used.

Overall, condom was more consistently used when respondents had sex with a non-steady
partner, or during paid sex, and less with a steady partner. This may relate to the high level of
discrimination that waria often faced, causing them to feel the need to assert their gender identity
and fulfill the need of their partner to not use condom that interferes in the pleasure and intimacy
with a steady partner (Siyan, 2019).

Table 4.18 Other Risk Behavior of Waria

Silicone Injection/
District/Municipality n Had injected drugs (%) Tattoo (%) Piercing (%)
Hormonal Therapy (%)

Aceh Besar# 63 4.8 3.2 36.5 42.9

Pematang Siantar City 249 0.8 38.2 66.7 8.0

Palembang City 234 2.6 20.9 42.3 22.2

Bandar Lampung City 134 3.7 35.8 39.6 25.4

Tanjung Pinang City# 54 7.4 16.7 33.3 25.9

West Jakarta City 224 1.8 12.9 12.5 13.4

Bogor 250 0.0 31.2 76.8 58.8

Purwakarta 250 1.2 26.4 55.2 21.2

Bekasi 250 1.2 8.4 66.4 23.2

Depok City 200 0.5 15.5 70.5 54.5

Banyumas 120 0.0 25.0 65.8 20.0

Yogyakarta City 100 3.0 22.0 80.0 56.0

Banyuwangi 105 0.0 26.7 64.8 20.0

Sumenep 215 0.9 11.2 27.4 21.4

Mojokerto City# 24 0.0 12.5 66.7 33.3

Madiun City# 22 0.0 22.7 77.3 36.4

Surabaya City 209 1.0 26.8 77.5 45.0

Kupang City# 15 0.0 40.0 93.3 26.7

Pontianak City 220 0.5 10.9 58.6 32.3

83
 Silicone Injection/
District/Municipality n Had injected drugs (%) Tattoo (%) Piercing (%)
Hormonal Therapy (%)

Palangka Raya City# 43 0.0 41.9 65.1 34.9

Ambon City# 72 1.4 30.6 59.7 12.5

Aggregate 2760 1.2 21.8 56.5 29.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Another risk behavior that waria respondents reported was substance abuse, consisting of
marijuana, methamphetamine (ekstasi), crystal meth (sabu), etc. Overall, 7.0% of respondents
used drugs, and 1.2% injected drugs. The majority of injecting drug users was found in Bandar
Lampung City (35.8%). In contrast, 3 Districts/Municipalities, Bogor, Banyumas and Banyuwangi
Districts, had no respondents who injected drugs.

Tattooing and piercing was another risk behavior that 21.8% and 56.5% waria respondents did
respectively. In Pematang Siantar City, 38.2% of respondents received tattoo, the highest
percentage among other sites. Piercing was the highest among respondents in Yogyakarta City
(80.0%) and Surabaya City (77.5%).

Waria respondents also received silicone injection or hormonal therapy, another risk behavior. It
was done by 29.5% respondents as a common procedure that waria do for the purpose of
feminization or to make their appearance look more like the gender they identify with. People
often assume one’s gender based on physical appearance so hormonal therapy can help waria to
be recognized as having the gender they regard as suitable (UNDP, 2013). The highest percentage
of respondents who obtained silicone injection was found in Bogor District (58.8%) and
Yogyakarta City (56.0%). Hormonal therapy was so commonly done for waria that they would
often perform the injection themselves without counseling about safe injection practices. This
essentially made them vulnerable to HIV infection due to needle sharing practices (Herbst, 2008).

4.5 Sexually-Transmitted Infection (STI)

This section presents information on sexually-transmitted infection (STI), the symptoms
respondents experienced, their knowledge and opinion about STI testing, history of STI that
respondents ever had, intervention and efforts performed to avoid STI transmission. Symptoms
that were explored included a. Pain (burning sensation) during urination b. wart in the genital
area c. wart in the anal area d. sore or ulcer in the genital area e. sore or ulcer around the anus f.
abnormal discharge from the penis g. abnormal discharge from the anus h. lumps or swelling
around the anus. Symptoms of ulcer or sores can indicate herpes or syphilis, while lumps around
the genital can be symptoms of condyloma (jengger ayam) or LGV (Limphogranuloma Vereneum),
while kencing nanah (pus in urine / gonorrhea) can indicate an STI.

84
 Table 4.19 STI Symptoms and Testing among Waria

STI Symptom (%)

Sought health
Had STI Abnormal Sore or
Sore or ulcer Wart Pain (burning care in the last
District/Municipality n Symptom* discharge ulcer
around the around sensation) 6 months
(%) from the around the
anus the anus when urinate (%)
penis genital
Aceh Besar# 63 6.3 1.6 1.6 1.6 1.6 3.2 19.0

Pematang Siantar City 249 24.1 0.8 2.8 2.4 4.0 13.7 16.5

Palembang City 234 9.4 0.4 2.1 3.9 1.7 3.9 26.1

Bandar Lampung City 134 6.7 1.5 1.5 0.0 0.0 4.5 21.6

Tanjung Pinang City# 54 18.5 0 0 0.0 0.0 18.5 14.8

West Jakarta City 224 10.7 0 1.8 0.5 1.3 5.8 25.4

Bogor 250 3.6 0.8 0.4 1.2 2.0 1.2 26.0

Purwakarta 250 13.6 0.4 3.2 2.0 3.6 7.2 22.8

Bekasi 250 6.8 0 0 0.8 1.6 2.8 41.2

Depok City 200 12.0 2 3.5 1.5 0.5 4.0 21.5

Banyumas 120 18.3 8.3 0 0.8 0.0 15.8 25.0

Yogyakarta City 100 18.0 2 7 4.0 7.0 7.0 18.0

Banyuwangi 105 7.6 2.9 0.9 1.0 2.9 1.9 9.5

Sumenep 215 28.4 3.3 9.8 11.6 0.9 11.6 22.3

Mojokerto City# 24 4.2 0 0 0.0 0.0 0.0 37.5

Madiun City# 22 0.0 0 0 0.0 0.0 0.0 36.4

Surabaya City 209 9.6 1.9 0 1.4 0.5 1.9 10.0

Kupang City# 15 26.7 0 0 0.0 0.0 6.7 6.7

Pontianak City 220 2.7 0 0.9 0.0 0.5 0.5 37.7

Palangka Raya City# 43 20.9 13.9 13.9 4.7 0.0 7.0 27.9

Ambon City# 72 11.1 1.4 1.4 0.0 1.4 8.3 23.6

Aggregate 2760 12.1 1.4 2.4 2.3 1.8 5.7 27.9

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *a composite
variable from several variables of STI symptoms that respondents experience.

The table above lists five STI symptoms that respondents experienced. Pain (burning sensation)
during urination was experienced by 5.7% respondents, the highest proportion was in Banyumas
District (15.8%). Sores or ulcer around the anus was experienced by 2.4% respondents, the
highest proportion (9.8%) was found in Sumenep District, while in Banyumas District and
Surabaya City no respondents reported getting the symptom. A similar percentage of respondents
(2.3%) got sores or ulcer around the genital area, with Sumenep having the highest proportion
(11.6%), and Bandar Lampung City and Banyumas District with zero proportion. Fewer
respondents (1.8%) had anal wart and 1.4% experienced abnormal discharge from the penis.
Anal wart was experienced by 7.0% respondents in Yogyakarta City and abnormal penile
discharge was experienced by 8.33% respondents in Banyumas District.

85
 In table 4.19, respondents were categorized as having STI symptoms if in the last year, they
experienced one of the eight symptoms mentioned above. Overall, 12.1% of respondents had at
least one symptom in the last year. The highest proportion was found in Sumenep District
(28.4%), and the lowest was in Pontianak City (2.7%). Only 27.9% of respondents had STI tests
in the last six months. This may relate to discriminatory attitudes or words that often discouraged
waria from going to an STI clinic independently. A lot of waria also felt embarrassed to openly
visit an STI clinic (Rahmawati, 2013).

Table 4.20 STI Testing Site, Consultation with a Health Provider and STI Treatment Facility that Waria Visited
Location of Last STI Test (%) Visited a Treatment Location2 (%)
health
Suggested STI
provider Private
District/Municipality n1 Private NGO Mobile PKM/ Test to Steady
PKM Hospital Other when had STI Doctor’s Other
Clinic Clinic STI Hosp Partner3 (%)
symptoms Practice
(%)
Aceh Besar# 7 100.0 0.0 0.0 0.0 0.0 0.0 57.1 75.0 25.0 0.0 100.0

Pematang Siantar City 108 53.7 0.9 0.9 9.3 33.3 1.9 59.3 96.9 3.1 0.0 51.6

Palembang City 82 76.8 13.4 0.0 1.2 8.5 0.0 30.5 96.0 0.0 4.0 40.0

Bandar Lampung City 23 91.3 0.0 4.3 0.0 4.3 0.0 13.0 100.0 0.0 0.0 85.0

Tanjung Pinang City # 46 100.0 0.0 0.0 0.0 0.0 0.0 73.9 100.0 0.0 0.0 75.0

West Jakarta City 37 89.2 0.0 0.0 0.0 10.8 0.0 54.1 100.0 0.0 0.0 80.0

Bogor 18 83.3 0.0 5.6 0.0 11.1 0.0 33.3 83.3 16.7 0.0 33.3
Purwakarta 41 65.9 9.8 9.8 0.0 9.8 4.9 46.3 63.2 36.8 0.0 79.2
Bekasi 108 98.1 0.0 0.0 0.0 1.9 0.0 75.9 98.8 1.2 0.0 100.0
Depok City 12 91.7 0.0 0.0 0.0 0.0 8.3 75.0 100.0 0.0 0.0 20.0
Banyumas 26 80.8 11.5 3.8 3.8 0.0 0.0 30.8 75.0 25.0 0.0 72.7
Yogyakarta City 56 78.6 10.7 0.0 3.6 7.1 0.0 48.2 100.0 0.0 0.0 42.9
Banyuwangi 75 92.0 1.3 0.0 0.0 6.7 0.0 12.0 100.0 0.0 0.0 20.0
Sumenep 8 75.0 0.0 0.0 0.0 25.0 0.0 75.0 33.3 50.0 16.7 85.7
Mojokerto City# 15 73.3 6.7 0.0 0.0 13.3 6.7 46.7 100.0 0.0 0.0 100.0
Madiun City# 7 100.0 0.0 0.0 0.0 0.0 0.0 14.3 100.0 0.0 0.0 63.9
Surabaya City 185 73.5 0.5 0.0 0.0 25.9 0.0 36.2 91.0 1.5 7.5 37.5
Kupang City# 10 10.0 60.0 0.0 20.0 10.0 0.0 10.0 100.0 0.0 0.0 40.0
Pontianak City 148 91.2 0.0 0.0 0.0 8.8 0.0 12.2 100.0 0.0 0.0 42.9

Palangka Raya City# 10 40.0 10.0 0.0 0.0 50.0 0.0 70.0 100.0 0.0 0.0 100.0
Ambon City# 28 75.0 7.1 3.6 0.0 14.3 0.0 39.3 100.0 0.0 0.0 51.6

Aggregate 927 80.4 2.9 0.9 1.5 13.8 0.5 39.2 93.4 4.7 1.9 57.1
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; ^PKM (Puskesmas);
1Number of respondents who underwent STI test. 2Among respondents who had consulted a health provider; 3Among respondents

who had a steady partner.

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Respondents who had ever been tested for STI were 33.6% (927 respondents). As an aggregate,
most STI tests were performed in Puskesmas (80.4%). In all Districts/Municipalities, Puskemas
was respondents’ facility of choice for STI tests. In Bandar Lampung City, Bekasi District, Depok
City, Banyuwangi District and Pontianak City, more than 90% of STI tests were performed in
Puskesmas. In Bekasi District the percentage was even close to 100%. After Puskesmas, the
second most common STI testing facility was the Mobile STI (13.8%). In Pematang Siantar City
the proportion was quite high (33.3%). Other facilities that respondents visited for STI test were
Hospital (2.9%), NGO clinic (1.5%) and private clinic (0.9%).

Upon experiencing STI symptoms, 39.2% respondents consulted with a health provider. In Bekasi
District, the proportion was quite high (75.9%), but in Banyuwangi District it was only 12.0%.
The majority of respondents (93.4%) chose to go to a Puskesmas and only 4.7% went to a doctor’s
private practice. In Bandar Lampung City, West Jakarta City, Depok City, Yogyakarta City,
Banyuwangi District and Pontianak City, all respondents went to Puskesmas for STI service
(100%), but in Sumenep District, 50.0% of respondents chose to visit a doctor’s private practice,
and only 33.3% went to Puskesmas.

The survey also showed that only 57.1% of respondents with a steady partner suggested STI
testing to their partner, except in Bekasi District where all respondents told their steady partner
to be tested for STI.

Treatment delay, unsafe sex, and failure to get one’s partner to be tested were factors that caused
STIs to spread. All these factors were closely related with socio-cultural practices that are
prevalent in the community. STIs are still considered as a consequence of improper behavior and
as a result many individuals with STI were inclined to hide their condition. The society also often
regard people with STI as sinful individuals who had violated societal norms. As a result, many
people delay health care and treatment (Rahmawati, 2013).

4.4 HIV Program Coverage

Waria is a population group who is at risk of getting HIV/AIDS, and HIV test is one way to prevent
transmission. It allows entry to prevention, care, support and treatment services. As already
known, early identification of an HIV positive status will maximize the opportunity of people with
HIV/AIDS to receive treatment, significantly reduce HIV-related illnesses, prolong life, as well as
prevent transmission to sexual partners (Azinar, 2018).

This section presents the coverage of HIV test in the waria population. Testing was categorized as
test on respondent’s own initiative, test based on referral, test on both respondent’s own initiative
and based on referral, and lastly never got HIV test.

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 Table 4.21 HIV Testing among Waria
HIV Test (%) HIV test in Consent for Received
Yes, HIV test Yes, HIV Yes, HIV test on the last HIV test was counseling before
District/Municipality n
on own test based own initiative and Never year* obtained* receiving result*
initiative on referral based on referral (%) (%) (%)

Aceh Besar# 63 31.7 0.0 0.0 68.3 85.0 95.0 75.0

Pematang Siantar City 249 10.0 14.1 29.3 46.6 100.0 71.4
86.4

Palembang City 234 27.8 18.8 41.5 12.0 94.7 100.0 99.5

Bandar Lampung City 134 23.1 6.0 47.8 23.1 98.1 95.1
94.2
Tanjung Pinang City# 54 96.3 1.9 1.9 0.0 96.3 100.0 100.0

West Jakarta City 224 50.0 8.5 27.7 13.8 95.9 92.7 92.7

Bogor 250 15.6 19.2 55.6 9.6 95.6 98.7 98.7

Purwakarta 250 41.2 7.6 22.0 29.2 82.9 91.5 92.7

Bekasi 250 18.0 3.2 37.2 41.6 95.2 100.0 99.3

Depok City 200 14.0 21.0 38.5 26.5 96.6 98.6 98.0

Banyumas 120 6.7 8.3 60.8 24.2 95.6 100.0 100.0

Yogyakarta City 100 58.0 9.0 27.0 6.0 77.7 97.9 95.7

Banyuwangi 105 6.7 19.0 61.0 13.3 85.7 100.0 100.0

Sumenep 215 0.0 1.4 1.4 97.2 66.7 100.0 66.7

Mojokerto City# 24 45.8 12.5 33.3 8.3 90.9 100.0 90.9

Madiun City# 22 68.2 4.5 22.7 4.5 95.2 100.0 100.0

Surabaya City 209 38.8 2.4 53.6 5.3 81.8 99.5 100.0

Kupang City# 15 33.3 6.7 53.3 6.7 85.7 100.0 92.9

Pontianak City 220 12.7 2.3 65.5 19.5 94.9 100.0 100.0

Palangka Raya City# 43 32.6 11.6 39.5 16.3 86.1 100.0 97.2

Ambon City# 72 19.4 43.1 13.9 23.6 98.2 98.2 94.5

Aggregate 2760 22.8 10.0 39.2 28.0 90.7 98.0 95.8

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who have had HIV test.

Based on aggregate data, 72.0% respondents were tested for HIV, 22.8% of them took the
initiative to get tested, 10.0% were tested due to referral, and 39.2% were tested on their own
initiative as well as referred for testing. There was still 28.0% of respondents who never had HIV
test. From all the respondents who had been tested, 90.7% were tested in the last year. The
highest proportion of respondents who initiated testing was found in Yogyakarta City (58.0%),
which demonstrated their high level of awareness about the need to know their status.

The IBBS survey also found that the practice to request consent prior to HIV testing was
implemented at a very high level (98.0%). In Pematang Siantar City, Palembang City, Bekasi,

88
 Banyumas, Banyuwangi, Sumenep Districts and Pontianak City consent was obtained from all
respondents before HIV test (100%). The lowest percentage was found in Purwakarta District
(91.5%). Aside from consent, respondents also received pre-test counseling before results were
disclosed. Overall the percentage of pre-test counseling was 95.8%, and all survey sites had above
90% pre-test counseling, except Pematang Siantar City (71.4%) and Sumenep District (66.7%).
In Banyumas, and Banyuwangi Districts, Surabaya City and Pontianak City all respondents
received pre-test counseling (100%).

Table 4.22 Receipt of Test Result and Reason for Getting HIV Test among Waria

Primary Reason for Getting HIV Test (%)

Recommended
Requested/ Requested/ Received Received
HIV Test to
recommended recommended Requested/ Test Result in
District/Municipality n1 Feel Steady
by a Field/ / referred by recommended Other Result 2 hours2
at-risk (%) Partner3
Outreach a Health by a Friend (%)
(%)
Worker Worker
Aceh Besar# 20 30.0 0.0 10.0 40.0 20.0 60.0 0.0 27.1

Pematang Siantar City 133 54.9 25.6 6.8 9.8 3.0 78.2 51.9 26.4

Palembang City 206 56.3 36.4 2.4 2.9 1.9 97.1 98.0 47.6

Bandar Lampung City 103 49.5 14.6 16.5 14.6 4.9 96.1 100.0 36.1

Tanjung Pinang City # 54 94.4 1.9 0.0 1.9 1.9 96.3 94.2 66.7

West Jakarta City 193 76.7 7.8 4.7 1.6 9.3 91.2 59.1 40.6

Bogor 226 64.6 18.6 12.8 1.8 2.2 86.3 69.7 51.0

Purwakarta 177 65.5 6.8 15.8 9.0 2.8 87.6 47.7 30.9

Bekasi 146 83.6 11.6 2.7 0.0 2.1 92.5 100.0 31.1

Depok City 147 64.6 25.9 4.1 4.8 0.7 98.6 95.9 71.7

Banyumas 91 16.5 73.6 2.2 4.4 3.3 100.0 96.7 31.4

Yogyakarta City 94 67.0 13.8 5.3 2.1 11.7 97.9 93.5 63.4

Banyuwangi 91 61.5 38.5 0.0 0.0 0.0 100.0 97.8 32.9

Sumenep 6 0.0 16.7 50.0 33.3 0.0 100.0 50.0 2.4

Mojokerto City# 22 77.3 9.1 4.5 4.5 4.5 95.5 100.0 81.8

Madiun City# 21 66.7 19.0 14.3 0.0 0.0 95.2 100.0 90.0

Surabaya City 198 37.9 59.1 1.5 0.5 1.0 98.0 78.4 42.3

Kupang City# 14 71.4 7.1 14.3 7.1 0.0 100.0 71.4 50.0

Pontianak City 177 51.4 41.8 6.2 0.0 0.6 99.4 73.3 39.6

Palangka Raya City# 36 72.2 5.6 8.3 8.3 5.6 66.7 54.2 36.7
Ambon City# 55 43.6 40.0 7.3 3.6 5.5 89.1 75.5 41.3

Aggregate 1988 58.7 27.9 6.6 3.7 3.1 93.5 79.8 36.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; 1Number of
respondents who have had HIV test. 2Among respondents who receive the result of their last HIV test; 3Among respondents who had
a steady partner.

In general respondents received HIV test because of a variety of reasons. They felt at risk, they
were asked or requested to be tested by a field/outreach worker, or a health provider, or friends,

89
 and others. Overall, 58.7% of respondents got tested because they felt they were at risk. Others
followed the recommendation of a field/outreach worker (27.9%) or a health provider (6.6%).

All respondents who were tested for HIV should actually receive their test result, but the
aggregate data showed that only 93.5% did. In Banyumas, Banyuwangi and Sumenep Districts, all
respondents received their HIV test result (100%) but in Pematang Siantar City only 78.2%
respondents did. The waiting period until results became available also varied from district to
district. Overall, 79.8% of respondents received their test result in 2 hours, but some respondents
(4.3%) had to wait for more than one day, which made them reluctant to return to the health
facility to pick up their test result.

Recommending partners to get tested is another important action, but only 36.0% of respondents
asked their steady partner to get tested, and 21.83% had HIV test. The highest proportion of
respondents who suggested HIV test to their steady partner was in Depok City (71.7%) and the
lowest was in Sumenep District (2.4%).

Table 4.23 Reason for Not Getting HIV Test among Waria

Reasons for Not Getting HIV Test (%)

Do not know
District/Municipality n* Test Do not want Do not know
Feel healthy/ Service is where the
facility is to know HIV that HIV test Other
not at-risk costly service is
far status is needed
available
Aceh Besar# 43 69.8 0.0 2.3 20.9 2.3 4.7 0.0

Pematang Siantar City 116 25.0 1.7 0.9 34.5 13.8 24.1 0.0

Palembang City 28 42.9 0.0 0.0 32.1 0.0 25.0 0.0

Bandar Lampung City 31 54.8 0.0 0.0 12.9 3.2 22.6 6.5

Tanjung Pinang City # 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

West Jakarta City 31 35.5 12.9 3.2 9.7 16.1 19.4 3.2

Bogor 24 20.8 0.0 0.0 29.2 0.0 41.7 8.3

Purwakarta 73 47.9 1.4 0.0 4.1 12.3 21.9 12.3

Bekasi 104 32.7 4.8 0.0 37.5 8.7 13.5 2.9

Depok City 53 24.5 0.0 0.0 66.0 3.8 5.7 0.0

Banyumas 29 44.8 3.4 0.0 27.6 0.0 20.7 3.4

Yogyakarta City 6 66.7 0.0 0.0 0.0 0.0 16.7 16.7

Banyuwangi 14 14.3 7.1 0.0 28.6 14.3 28.6 7.1

Sumenep 209 17.2 5.7 0.0 23.9 2.9 50.2 0.0

Mojokerto City# 2 50.0 0.0 0.0 50.0 0.0 0.0 0.0

Madiun City# 1 100.0 0.0 0.0 0.0 0.0 0.0 0.0

Surabaya City 11 54.5 0.0 0.0 9.1 0.0 27.3 9.1

Kupang City# 1 100.0 0.0 0.0 0.0 0.0 0.0 0.0

Pontianak City 43 46.5 0.0 0.0 16.3 0.0 34.9 2.3

Palangka Raya City# 7 28.6 0.0 0.0 0.0 28.6 42.9 0.0

90
 Reasons for Not Getting HIV Test (%)
Do not know
District/Municipality n* Test Do not want Do not know
Feel healthy/ Service is where the
facility is to know HIV that HIV test Other
not at-risk costly service is
far status is needed
available
Ambon City# 17 58.8 0.0 0.0 5.9 11.8 0.0 23.5

Aggregate 772 30.7 3.4 0.3 27.2 6.5 29.1 2.8

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who never had HIV tests.

Based on aggregate data 28.0% of respondents had not been tested for HIV. A third (30.7%) said
it was because they felt healthy or not at risk. In Yogyakarta City, 66.7% of respondents felt that
way and therefore did not get tested. Another reason for not getting tested was because
respondents did not wish to know their status (27.2%), and the highest proportion of those with
that reason was found in Depok City (66.0%).
The survey also showed that 29.1% of respondents did not get tested because they did not know
they needed HIV test. In fact, 6.5% of respondents did not get tested because they did not know
where to go for testing.

Table 4.24 Location of Last HIV Test and Reason for Not Disclosing HIV Test Result among Waria

Location of Last HIV Test (%) Reason for not Disclosing HIV Test Result (%)

District/ Fear of
n* n** Fear of Fear of
Municipality Private NGO Mobile Fear of Being
PKM Hosp Other Losing Losing a Other
Clinic Clinic VCT Discrimination Shunned
Job Partner
by Family
Aceh Besar# 20 90.0 0.0 0.0 10.0 0.0 0.0 0 0 0 0 0 0

Pematang Siantar
133 51.9 1.5 0.0 6.0 40.6 0.0 49 61.2 53.1 28.6 28.6 2.0
City
Palembang City 206 62.1 12.1 0.5 7.3 18.0 0.0 77 76.6 29.9 32.5 67.5 0.0

Bandar Lampung
103 81.6 4.9 1.0 1.0 10.7 1.0 24 62.5 0.0 4.2 4.2 25.0
City
Tanjung Pinang
54 96.3 0.0 0.0 0.0 3.7 0.0 20 70.0 10.0 5.0 10.0 0.0
City #
West Jakarta City 193 90.2 1.0 0.0 4.1 4.7 0.0 8 50.0 25.0 12.5 0.0 0.0

Bogor 226 42.9 1.8 0.0 2.2 53.1 0.0 123 69.9 2.4 3.3 11.4 8.1

Purwakarta 177 63.3 5.6 2.8 1.1 25.4 1.7 21 76.2 9.5 4.8 14.3 4.8

Bekasi 146 90.4 0.0 0.0 2.1 7.5 0.0 71 85.9 0.0 4.2 5.6 8.5

Depok City 147 49.7 1.4 0.0 37.4 11.6 0.0 74 87.8 2.7 8.1 36.5 5.4

Banyumas 91 54.9 8.8 0.0 13.2 23.1 0.0 7 100.0 0.0 14.3 42.9 0.0

Yogyakarta City 94 27.7 9.6 2.1 30.9 29.8 0.0 34 47.1 0.0 0.0 2.9 44.1

Banyuwangi 91 82.4 2.2 0.0 1.1 14.3 0.0 22 40.9 0.0 0.0 22.7 40.9

Sumenep 6 50.0 0.0 0.0 0.0 50.0 0.0 2 50.0 2.0 50.0 100.0 0.0

Mojokerto City# 22 59.1 13.6 0.0 0.0 22.7 4.5 15 46.7 14.0 6.7 33.3 40.0

Madiun City# 21 90.5 4.8 0.0 0.0 4.8 0.0 2 0.0 2.0 0.0 0.0 0.0

Surabaya City 198 72.7 2.0 0.0 0.5 24.2 0.5 16 50.0 16.0 12.5 6.3 31.3

Kupang City# 14 0.0 50.0 0.0 7.1 42.9 0.0 6 50.0 5.0 16.7 50.0 0.0

Pontianak City 177 84.7 1.1 0.0 0.0 14.1 0.0 85 82.4 83.0 8.2 23.5 0.0

91
 Location of Last HIV Test (%) Reason for not Disclosing HIV Test Result (%)

District/ Fear of
n* n** Fear of Fear of
Municipality Private NGO Mobile Fear of Being
PKM Hosp Other Losing Losing a Other
Clinic Clinic VCT Discrimination Shunned
Job Partner
by Family
Palangka Raya
36 0.0 16.7 0.0 0.0 83.3 0.0 7 57.1 7.0 57.1 71.4 0.0
City#
Ambon City# 55 67.3 5.5 1.8 3.6 20.0 1.8 17 29.4 17.0 11.8 11.8 29.4

Aggregate 1988 66.2 3.8 0.5 7.0 22.0 0.3 613 72.9 9.8 10.8 24.0 9.3
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who have had HIV test; **Number of respondents who received their test result but did not disclose the result to other
people.

The majority of the last HIV test that respondents had was performed in Puskesmas (66.2%). The
proportion was even higher in West Jakarta (90.2%) and Bekasi District (90.4%). The second
location of choice for HIV test was the mobile VCT (22.0%), but in Bogor District, respondents
preferred mobile VCT (53.1%) to Puskesmas (42.9%). In contrast, in West Jakarta, only 4.7% of
respondents received HIV test through a mobile VCT service. Other respondents chose to get HIV
test from an NGO clinic (7.0%) or hospital (3.8%). NGO clinic was most preferred in Depok City
(37.4%) while hospital was most preferred by respondents in Palembang City (12.1%).

Among respondents who were tested and received their test result, 33.0% of them never
disclosed their test result to anyone else. Reasons for that include fear of discrimination (72.9%),
fear of being shunned by family (24.0%). All the respondents in Banyumas District who did not
disclose their test result stated they were worried about discrimination (100%). Discrimination
against HIV-positive people usually occurs due to lack of knowledge and misconceptions
regarding transmission of HIV. Other reasons that respondents stated were fear of losing thir
partner (10.8%) and fear of losing their job (9.8%).

Table 4.25 HIV Treatment and Viral Load Test among Waria

Viral Load Know the Viral

Is Taking ARV Stopped taking Viral Load
District/ Receive Test in the last Load Test
n1 until now2 ARV for more than Test2
Municipality ARV (%) ≤12 Months4 Result4
(%) 3 months3 (%) (%)
(%) (%)

Aceh Besar# 0 0.0 0.0 0.0 0.0 0.0 0.0

Pematang Siantar City 2 100.0 50.0 100.0 50.0 100.0 100.0

Palembang City 2 100.0 100.0 0.0 50.0 0.0 100.0

Bandar Lampung City 4 100.0 100.0 50.0 100.0 100.0 75.0

Tanjung Pinang City# 0 0.0 0.0 0.0 0.0 0.0 0.0

West Jakarta City 5 100.0 100.0 0.0 100.0 100.0 100.0
Bogor 6 100.0 83.3 20.0 66.7 100.0 75.0
Purwakarta 28 92.9 92.3 25.0 42.3 54.5 90.9
Bekasi 3 100.0 100.0 0.0 33.3 100.0 100.0
Depok City 1 100.0 100.0 0.0 0.0 0.0 0.0
Banyumas 8 100.0 87.5 0.0 25.0 50.0 50.0

92
 Viral Load Know the Viral
Is Taking ARV Stopped taking Viral Load
District/ Receive Test in the last Load Test
n1 until now2 ARV for more than Test2
Municipality ARV (%) ≤12 Months4 Result4
(%) 3 months3 (%) (%)
(%) (%)
Yogyakarta City 22 100.0 100.0 18.2 50.0 72.7 100.0
Banyuwangi 15 93.3 92.9 15.4 14.3 50.0 100.0
Sumenep 0 0.0 0.0 0.0 0.0 0.0 0.0
Mojokerto City# 0 0.0 0.0 0.0 0.0 0.0 0.0
Madiun City# 2 50.0 100.0 0.0 100.0 100.0 0.0
Surabaya City 27 100.0 96.3 42.3 55.6 60.0 46.7
Kupang City# 0 0.0 0.0 0.0 0.0 0.0 0.0
Pontianak City 2 100.0 100.0 0.0 0.0 0.0 0.0
Palangka Raya City# 2 100.0 50.0 0.0 0.0 0.0 0.0
Ambon City# 3 100.0 100.0 0.0 0.0 0.0 0.0

Aggregate 125 97.6 94.3 23.5 46.7 70.2 78.9

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; 1Number
of HIV-positive
respondents who enrolled in CST service; 2Among respondents who ever received ARV; 3Among respondents who are still taking ARV until now;
4Among respondents who ever had a viral load test.

From the total respondents with positive HIV test result (based on what the respondent stated in
the questionnaire) 89.3% enrolled in a CST (care, support, treatment) service. Among those,
97.6% received ARV. All PLHIV received ARV except in two Districts (Purwakarta and
Banyuwangi Districts). At the time of the survey interview, 94.3% of respondents were still taking
ARV, while 23.5% respondents admitted to stop taking ARV for more than 3 months in the past.

Respondents who were getting ARV were also asked if they ever received a viral load test, and
46.7% of them did. In Bandar Lampung City and West Jakarta, all the respondents received a viral
load test (100%).
Within the past year, 70.2% of respondents had a viral load test, and from those 78.9% received
their test result.

4.5 Tuberculosis, Hepatitis B and Hepatitis C

The IBBS survey also gathered information on the coverage of TB, Hepatitis B and Hepatitis C
intervention program. The table below presents data on testing coverage, testing result receipt,
knowledge about the test result and treatment.

Table 4.26 Coverage of Program and Treatment for TB, Hepatitis B and C among Waria

Receive TB Had been Know the Had been Know the

Had been Know the test
treatment tested for Hep B Test tested for Hep C Test
District/Municipality n tested for TB result*
package* Hep B Result** Hep C Result**
(%) (%)
(%) (%) (%) (%) (%)
Aceh Besar# 63 0.0 0.0 0.0 0.0 0.0 0.0 0.0

93
 Receive TB Had been Know the Had been Know the
Had been Know the test
treatment tested for Hep B Test tested for Hep C Test
District/Municipality n tested for TB result*
package* Hep B Result** Hep C Result**
(%) (%)
(%) (%) (%) (%) (%)

Pematang Siantar City 249 2.8 100.0 28.6 0.8 100.0 0.0 0.0

Palembang City 234 2.1 80.0 60.0 0.9 100.0 0.0 0.0

Bandar Lampung City 134 5.2 100.0 28.6 3.7 100.0 0.7 100.0

Tanjung Pinang City# 54 40.7 100.0 63.6 14.8 100.0 9.3 100.0

West Jakarta City 224 7.6 100.0 64.7 8.9 95.0 10.7 91.7

Bogor 250 2.4 83.3 50.0 0.4 100.0 0.4 100.0

Purwakarta 250 5.2 84.6 30.8 3.2 75.0 1.2 100.0

Bekasi 250 1.6 100.0 0.0 0.0 0.0 0.0 0.0

Depok City 200 2.0 100.0 50.0 0.5 100.0 0.0 0.0

Banyumas 120 3.3 100.0 0.0 4.2 100.0 0.0 0.0

Yogyakarta City 100 31.0 96.8 19.4 16.0 93.8 5.0 100.0

Banyuwangi 105 5.7 100.0 66.7 0.0 0.0 1.0 100.0

Sumenep 215 1.4 100.0 0.0 0.0 100.0 0.0 0.0

Mojokerto City# 24 33.3 87.5 0.0 58.3 92.9 25.0 100.0

Madiun City# 22 9.1 50.0 50.0 13.6 100.0 4.5 100.0

Surabaya City 209 11.5 95.8 12.5 5.3 81.8 1.9 75.0

Kupang City# 15 6.7 100.0 0.0 13.3 100.0 0.0 0.0

Pontianak City 220 1.4 66.7 33.3 1.4 100.0 0.0 0.0

Palangka Raya City# 43 2.3 100.0 0.0 0.0 100.0 0.0 0.0

Ambon City# 72 8.3 66.7 0.0 5.6 100.0 0.0 0.0

Aggregate 2760 4.9 94.8 30.6 2.6 91.9 1.4 92.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who ever had a TB test; **Among respondents who ever had a hepatitis test.

Based on the aggregate data, 4.9% of respondents have been tested for TB. The highest proportion
was in Yogyakarta City (31.0%). Overall almost all respondents who were tested received their
test result (94.8%). In almost all survey sites, 100% of respondents who were tested for TB also
received their test result, except in Palembang City where only 80.0% of respondents received
their test result, also in Bogor District (83.3%), Purwakarta District (84.6%), Yogyakarta City
(96.8%), Surabaya City (95.8%) and Pontianak City (66.7%, the lowest proportion). Among
respondents who were tested, 30.6% received a treatment package, the highest proportion was
in Banyuwangi District (66.7%) and West Jakarta (64.7%).

For Hepatitis, 2.6% of respondents received Hepatitis B testing, higher than those who received
Hepatitis C test (1.4%). The highest proportion of Hepatitis B and Hepatitis B test was found in
Yogyakarta City (16.0%) and West Jakarta City (10.7%) respectively. As much as 91.9% received
their Hepatitis B test result, and 92.3% received their Hepatitis C test result.

94
 4.6 Coverage of Other Prevention Program
Other prevention programs are interventions and outreach that are performed by health
providers or field workers to the waria community as part of promotive and preventive effort.
The table below presents information about exposure of waria respondents to various
interventions.

Table 4.27 Waria’s Exposure to Intervention

Contacted by
Receive text Contact a
Meet or discuss Receive free field outreach
Receive message with hotline
with health Attend an condom worker to
printed information service to get
District/Municipality n worker / field edutaiment from field discuss HIV
material on HIV information
worker (%) outreach prevention/
(%) prevention about HIV
(%) worker (%) transmission
(%) (%)
(%)
Aceh Besar# 63 22.2 28.6 15.9 9.5 0.0 7.9 3.2

Pematang Siantar City 249 32.9 5.6 16.9 15.7 14.9 0.8 1.2

Palembang City 234 44.0 38.9 41.0 63.7 40.2 3.0 1.7

Bandar Lampung City 134 39.6 44.8 44.0 51.5 26.9 2.2 2.2

Tanjung Pinang City# 54 57.4 55.6 53.7 72.2 0.0 38.9 40.7

West Jakarta City 224 33.0 8.0 9.4 30.8 29.5 0.9 0.9

Bogor 250 38.0 22.8 14.4 63.6 24.0 4.0 3.2

Purwakarta 250 30.8 12.4 29.2 35.6 28.8 3.6 1.2

Bekasi 250 32.4 46.8 47.2 57.2 48.8 5.2 2.4

Depok City 200 56.5 50.5 25.0 70.5 53.0 1.5 0.0

Banyumas 120 63.3 10.8 54.2 48.3 40.0 0.8 0.8

Yogyakarta City 100 75.0 53.0 37.0 68.0 53.0 10.0 5.0

Banyuwangi 105 53.3 46.7 28.6 73.3 62.9 2.9 0.0

Sumenep 215 4.7 21.4 3.3 7.9 1.9 0.5 0.0

Mojokerto City# 24 79.2 70.8 37.5 54.2 0.0 33.3 12.5

Madiun City# 22 18.2 4.5 4.5 63.6 0.0 0.0 0.0

Surabaya City 209 62.7 43.5 63.6 69.4 67.9 6.7 3.3

Kupang City# 15 80.0 40.0 46.7 46.7 0.0 33.3 13.3

Pontianak City 220 28.2 5.9 5.9 50.0 27.3 3.2 2.7

Palangka Raya City# 43 32.6 37.2 23.3 44.2 0.0 4.7 4.7

Ambon City# 72 45.8 36.1 58.3 61.1 0.0 8.3 8.3

Aggregate 2760 39.4 27.3 28.3 48.3 35.1 3.1 1.7

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

As part of intervention activities, field outreach workers held meetings and discussions about
HIV/STI prevention and transmission, which were attended by 39.4% respondents. The highest
participation was by respondents in Yogyakarta City (62.7%). Other activities included
edutainment or waria art performance, which was attended by 27.3% respondents overall. The
highest participation was also found in Yogyakarta City (53.0%).

95
Information on HIV prevention and transmission was also disseminated through printed material
(booklet, brochure, calendar, leaflet) or audio-visual material, and 28.3% of respondents received
those in the last year. Respondents also received free condom from field/outreach workers
(48.3%), and in the last 3 months 35.2% of respondents were contacted by a field or outreach
worker for a discussion on HIV/STI prevention and transmission. This information provided
insight about how field workers had been actively working on disseminating information about
HIV/STI in the last 3 months.

Another information dissemination method was sending text messages about HIV prevention and
transmission, but only 3.1% of respondents ever received text messages of that nature. This
showed that respondents’ exposure to information through mobile phone was still very low. The
percentage of respondents who ever requested information on HIV through a hotline service was
even lower, at only 1.7%. This meants that waria respondents’ exposure to HIV information and
counseling service through phone was still very low.

4.7 Positivity Rate

This section presents the positivity rate of aggregate data for waria respondents. The total
number of respondents in HIV and Syphilis test was 2810 waria.

Hepatitis B and Hepatitis C test was performed only in Bogor, Purwakarta, Bekasi Districts and
Depok City of West Java Province to a total of 950 respondents.

Chlamydia and Gonorrhea test was performed in three Districts/Municipalities, but as an

aggregate, the proportion of Chlamydia, Gonorrhea, and Chlamydia-Gonorrhea mix among the
waria population was calculated with data from only 2 Districts/Municipalities (Bekasi District
and Surabaya City). Aceh Besar City was not included in the aggregate analysis due to its small
number of samples (60 respondents).

96
 16
13.9
95% CI (10,9-17,3)
14
11.9
95%CI (10,7-13,1)
12 9.9
95% CI (8,8-11,0) 8.6
10
95% CI (6,3-11,5)
8
5.1
6 95% CI (3,3-7,5)
2.9
4 95% CI (2,0-4,2) 1.6
95% CI (0,9-2,6)
2

0
HIV Syphilis Chlamydia Gonorrhea Chlamydia & Hep B Hep C
Gonorrhea

Figure 4.1 Positivity Rate among Waria

Based on the aggregate data, the prevalence of HIV among waria was 11.9% at 95%CI (10.7-13.1)
and the prevalence of Syphilis was 9.9% at 95%CI (8.8-11.0). Waria respondents were also tested
for Chlamydia and Gonorrhea, and respondents who were diagnosed with Chlamydia were 13.9%
at 95%CI (10.9-17.3). Respondents who were diagnosed with Gonorrhea were 8.6% at 95%CI
(6.3-11.5) and respondents who were diagnosed with a mixed Chlamydia and Gonorrhea
infection were 5.1% at 95%CI (3.3-7.5). In addition to HIV and STI, respondents in several cities
in West Java also received Hepatitis B and Hepatitis C test. The prevalence of Hepatitis B was 2.9%
at 95%CI (2.0-4.2) while the prevalence of Hepatitis C was slightly lower at 1.6% at 95%CI (0.9-
2.6).

Table 4.28 Proportion of Diseases among Waria per District/Municipality

Chlamydia and
HIV Syphilis Hep B Hep C Chlamydia Gonorrhea
District/Municipality n n Gonorrhea
(%) (%) (%) (%) (%) (%)
(%)
Aceh Besar# 64 6.3 3.1 60 1.7 1.7 1.7
Pematang Siantar City 250 7.2 13.2

Palembang City 248 9.7 10.9

Bandar Lampung City 134 14.9 3.7

Tanjung Pinang City# 54 5.6 13.0

West Jakarta City 223 6.7 6.7

Bogor 250 4.8 8.4 3.6 4.0

Purwakarta 250 20.0 13.2 2.4 0.0

Bekasi 250 13.2 14.0 4 1.2 248 12.4 8.4 5.6

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 Chlamydia and
HIV Syphilis Hep B Hep C Chlamydia Gonorrhea
District/Municipality n n Gonorrhea
(%) (%) (%) (%) (%) (%)
(%)
Depok City 200 3.5 3.0 1.5 1.0

Banyumas 101 14.2 11.7

Yogyakarta City 120 36.6 5.9

Banyuwangi 105 32.4 19.1

Sumenep 250 4.0 3.2

Mojokerto City# 24 20.8 20.8

Madiun City# 22 22.7 13.6

Surabaya City 209 21.1 13.4 206 15.6 8.8 4.4

Kupang City# 15 26.7 20.0

Pontianak City 220 5.9 12.3

Palangka Raya City# 50 40.0 4.0

Ambon City# 77 20.8 29.9

The above table shows that the highest proportion of HIV in the waria community was found in
Yogyakarta City (36.6%), also in Banyuwangi City at 32.4%. The lowest proportion was found in
Depok City (3.5%) and Sumenep District (4.0%).

The proportion of syphilis as an aggregate was 9.9%. Eight sites had a higher proportion, the
highest was Banyuwangi District with 19.1% proportion of syphilis, followed by Surabaya City
with 13.4% cases. The lowest proportion was reported from Depok City (3.0%).

Hepatitis test was performed on waria respondents in four Districts/Municipalities in West Java.
The highest proportion of Hepatitis B at 4.0% was found in Bekasi District, and the highest
proportion of Hepatitis C also at 4.0% was found in Bogor District. The lowest proportion of
Hepatitis B was found in Depok City (1.5%). For Hepatitis C the lowest proportion, at 0%, was
found in Purwakarta District.
Aggregate data for Chlamydia-Gonorrhea mixed infection (CT/NG) were from Surabaya City and
Bekasi District. The proportion of Chlamydia as a single infection in Surabaya City was higher
than that in Bekasi District (15.6% and 12.4% respectively). Similarly, Surabaya City also had a
higher proportion of Gonorrhea than Bekasi District (8.8% vs 8.4%). However, for “Chlamydia
and Gonorrhea” mixed infection, Bekasi District had a higher proportion (5.6%) than Surabaya
City (4.4%).

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 Female Sex Worker (FSW)
Female Sex Worker (FSW) is one key population that were recruited as respondents in the 2018-
2019 IBBS. Female Sex Workers are women who provide sexual service as primary or additional
source of income and receive payment in the form of money, goods or favor. There are direct and
indirect female sex workers but the 2018-2019 IBBS did not categorize female sex workers as
direct or indirect and instead combined them as one group of Female Sex Worker (FSW). This
survey defined FSW as women aged 15 years or older who provide sexual service as a primary or
additional source of income and receive payment in the form of money, goods or favor. The
women had sex with at least one client in the last month, was present at the survey location at the
time of the survey team’s visit and have resided in the survey city for at least one month.

This section describes the data analysis for the FSW group, which included the positivity rate of
HIV, Syphilis, Gonorrhea, Chlamydia, Chlamydia and Gonorrhea, Hepatitis B and C. The
characteristics of FSW is also described, their knowledge about HIV/AIDS, its risk and prevention
method, sexual behavior and prevention, intervention programs on HIV, TB, STI and Hepatitis B
and C, also exposure to those programs. The minimum sample required for the FSW group was
400 FSW in each selected District/Municipality. A total of 18 Districts/Municipalities in 13
Provinces were selected, so the total sample needed for the FSW group was 7200. Specimen for
Hepatitis B and C test was collected in three Districts/Municipalities in West Java Province. Up to
the end of survey, the total FSW respondents that was recruited had not met the target. Detailed
samples per District/Municipality are listed in Table 5.1 below.

Table 5.1 Data Collection and Participation Rate among FSW

Actual Actual Actual

Participation Participation Participation
District/Municipality Plan (Behavioral (Biological (Biological
Rate (%) Rate (%) Rate (%)
data) data - HIV) data - Syphilis)

Aceh
Simeulue* 400 73 18.3 80 20.0 80 20.0

West Sumatra
Bukittinggi City* 400 22 5.5 0 0.0 20 5.0

South
Sumatra
Ogan Komering 400 370 92.5 395 98.8 395 98.8
Ulu (OKU)
Bangka
belitung
Pangkal Pinang 400 384 96.0 391 97.8 391 97.8
City
Riau Islands
Batam City 400 385 96.3 400 100.0 400 100.0

DKI Jakarta

99
 Actual Actual Actual
Participation Participation Participation
District/Municipality Plan (Behavioral (Biological (Biological
Rate (%) Rate (%) Rate (%)
data) data - HIV) data - Syphilis)

South Jakarta 400 397 99.3 399 99.8 399 99.8

City
West Jakarta 400 400 100.0 400 100.0 400 100.0
City
North Jakarta 400 400 100.0 400 100.0 400 100.0
City
West Java
Sukabumi City 400 400 100.0 392 98.0 394 98.5

Bekasi City 400 399 99.8 400 100.0 400 100.0

Depok City 400 401 100.3 400 100.0 400 100.0

Central Java
Pekalongan City 400 397 99.3 395 98.8 395 98.8

East Java
Sumenep 400 400 100.0 400 100.0 400 100.0

Surabaya City 400 400 100.0 400 100.0 400 100.0

Bali
Gianyar 400 235 58.8 234 58.5 234 58.5

East
Kalimantan
Balikpapan City 400 202 50.5 212 53.0 212 53.0

Maluku
Maluku 400 59 14.8 60 15.0 60 15.0
Tenggara Barat*
Papua
Jayapura City 400 371 92.8 392 98.0 392 98.0

Total 7200 5695 79.1 5750 79.9 5772 80.2

In total 5695 FSW were interviewed for the behavioral component and 5779 specimens were
collected for the biological component. There was more biological data than behavioral data. The
participation rate for the behavioral component was 79.1%, while for the biological component
the number of samples for HIV test was 5750, a participation rate of 79.9%, and the number of
samples for syphilis test was 5772, at 80.2% participation rate. Overall, the participation rate for
both the behaviral and biological component of the survey was below 90%.
The participation rate between the 18 Districts/Municipalities varied extensively, both for the
behavioral and biological component. Some districts had a participation rate below 50%:
Bukittinggi City, Gianyar District, and Maluku Tenggara Barat District, and the lowest was in
Bukittinggi City (5.05% for the behavioral data and 0% or no biological data).

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 Table 5.2 Biological Data Collection and Participation Rate among FSW

Actual Actual
Participation Participation
District/Municipality Plan (Biological data Plan (Biological
Rate (%) Rate (%)
– HepB & C) data –CT/NG)

Aceh

Simeulue 400 63 15.8

DKI Jakarta
West Jakarta City 400 355 88.8
West Java
Sukabumi City 400 392 98.0
Bekasi City 400 400 100.0 400 320 80.0

Depok City 400 400 100.0

East Java
Sumenep 400 399 99.8
Bali
Gianyar 400 216 54.0

East Kalimantan
Balikpapan City 400 175 43.8

Total 1200 1192 99.3 1600 1528 95.5

Note:
Hepatitis B and C testing was not done in these districts/cities
CT/NG test was not done in these districts/cities

Several Districts/Municipalities had a 100% participation rate for both behavioral and biological
components of the survey. They were West Jakarta City, North Jakarta City, Bekasi City, Depok
City, Sumenep District and Surabaya City. Several Districts/Municipalities had a lower than 50%
participation rate, so data from these Districts/Municipalities were not included in the aggregate
analysis. They were Simuelue District (73 samples), Bukittinggi City (22 samples) and Maluku
Tenggara Barat District (59 samples).

Chlamydia and Gonorrhea test was performed on FSWs in six Districts/Municipalities: Simeulue
District, West Jakarta City, Bekasi City, Sumenep District, Gianyar District and Balikpapan City.
Simeulue District was the only site with a participation rate below 50% for the CT/NG biological
test (15.8%). Hepatitis B and C test was performed on FSWs in three cities in West Java Province
Bekasi City, Depok City and Sukabumi City, all with a coverage above 90% (Table 5.2).

5.1 Socio-demographic Characteristics of FSW

The risk for HIV infection varied significantly with respect to demographic characteristics. From
7200 FSWs who were planned to be recruited, 5695 agreed to be interviewed. Socio-demographic
characteristics were then collected, which consisted of survey sites, age, highest level of
education, marital status, permanent residence, current living arrangement, main occupation,
main source of income aside from sex work, identity card ownership, health insurance coverage,

101
 internet access, sex transaction venue, monthly income from sex work and occupation of client in
the last year. All the information obtained can be useful as input for health policy development to
address the HIV/AIDS problem, specifically among the FSW as one population who is at high risk
of HIV/AIDS infection.

5.1.1 Survey Venue

As shown in Table 5.3, overall the largest population of FSWs (44.4%) was found in
cafe/bar/discotheque/pub/karaoke bar, but in each District/Municipality, the venue where
FSWs were primarily found varied. In 11 Districts/Municipalities, the most common venue was
similar to the aggregate result, and the highest percentage of those venues was found in Batam
City (86.8%) and North Jakarta City (73.5%). The second most common venue (21.2%) was salon
and massage parlor and locations with the highest percentage of those venues were West Jakarta
City (64.3%), Surabaya City (52.0%) and South Jakarta City (45.6%). The least common venue for
FSWs overall was hotel/motel/cottage (1.5%). A higher proportion of FSWs was found by the
roadside/in the park/cemetery/along railroad track (9.9%) than in localization/brothels (8.2%).
Information about FSW venues can be used for outreach activities.

Table 5.3 Survey Venues of FSW

Survey Venues among FSWs (%)

District / Roadside/Park Hotel/ Café/Bar/ Salon/
n Localization “Dimly-lit” Rental
Municipality / Cemetery/ Motel/ Discotheque/ Massage Other
/ Brothel Food Stall Pub/ Karaoke Bar Room/ House
Railway Track Cottage Parlor
Simeulue# 73 4.1 0.0 21.9 0.0 1.4 15.1 6.8 50.7
Bukittinggi City# 22 50.0 0.0 0.0 0.0 0.0 0.0 50.0 0.0
Ogan Komering Ulu
370 0.0 0.5 9.7 1.4 48.6 39.7 0.0 0.0
(OKU)
Pangkal Pinang City 384 49.0 2.1 9.4 0.5 20.3 8.9 1.6 8.3
Batam City 385 7.5 0.0 0.0 4.7 86.8 0.8 0.0 0.3
South Jakarta City 397 0.0 2.0 0.0 0.3 56.2 41.6 0.0 0.0
West Jakarta City 400 0.0 0.8 0.0 5.0 28.8 64.3 0.0 1.3
North Jakarta City 400 1.8 0.5 3.0 3.3 73.5 14.3 3.5 0.3
Sukabumi City 400 1.5 23.0 0.3 0.0 31.8 0.0 42.8 0.8
Bekasi City 399 0.5 9.0 10.3 0.0 53.6 20.1 0.0 6.5
Depok City 401 0.0 25.4 16.2 0.0 28.2 21.9 8.0 0.2
Pekalongan City 397 13.6 52.9 13.1 0.0 20.4 0.0 0.0 0.0
Sumenep 400 25.3 5.3 2.0 5.5 8.5 0.0 39.0 14.5
Surabaya City 400 0.0 7.5 0.0 0.0 40.5 52.0 0.0 0.0
Gianyar 235 0.0 0.0 21.3 0.0 66.8 11.5 0.0 0.4
Balikpapan City 202 16.3 0.0 0.0 0.0 77.7 5.9 0.0 0.0
Maluku Tenggara
59 0.0 5.1 0.0 0.0 94.9 0.0 0.0 0.0
Barat#
Jayapura City 371 8.6 10.0 0.3 0.0 51.2 25.6 0.8 3.5
Aggregate 5541 8.2 9.9 5.5 1.5 44.4 21.2 6.9 2.5
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples
102
 5.1.2 Age

The median age of FSW as an aggregate was 27 years (Table 5.4), but between different
District/Municipality, the median age varied, from 25 (the youngest) in South Jakarta, North
Jakarta and Pekalongan City to 31 years old in Depok City. Seven Districts/Municipalities had
FSWs with median age below 27. They were Batam City (26 years), South Jakarta City (25 years),
West Jakarta City (26 years), North Jakarta City (25 years), Sukabumi City (26 years) and
Pekalongan City (25 years).

Most FSWs interviewed were between 25 to 49 years old (64.0%), who were considered as older
adult. The second largest group was the young adult at 20-24 years of age (27.4%) and this age
pattern applied to all the survey sites. The third largest group of FSWs was the teenagers (≤15-
19 years), and the smallest group was the older FSWs (≥50 years). A small percentage of very
young FSWs aged ≤15 years was found in several Districts/Municipalities (Table 5. 4), i.e. South
Jakarta City (11.3%), West Jakarta City (10.3%), North Jakarta City (17.3%), and Gianyar District
(11.9%).

Table 5.4 Age Group and Educational Level of FSW

Respondent’s Age (%) Respondent’s Educational Level (%)

Never Elementary High
District/Municipality n Median Age 15-19 Jr.High Sch/ College/
20-24 years 25-49 years ≥50 years went to School/ School/
years Equivalent University
school Equivalent Equivalent

Simeulue# 73 30 9.6 9.6 80.8 0.0 27.4 28.8 21.9 17.8 4.1

Bukittinggi City# 22 26 13.6 31.8 50.0 4.5 0.0 18.2 9.1 72.7 0.0

Ogan Komering Ulu 370 27 4.3 28.6 66.5 0.5 0.0 7.3 29.7 59.5 3.5
(OKU)
Pangkal Pinang City 384 28 5.5 27.6 65.4 1.6 0.5 21.4 45.6 31.8 0.8

Batam City 385 26 2.6 31.2 66.2 0.0 0.3 18.4 46.2 32.7 2.3

South Jakarta City 397 25 11.3 35.5 52.6 0.5 0.3 3.3 31.2 63.5 1.8

West Jakarta City 400 26 10.3 32.3 55.0 2.5 0.3 17.0 45.0 35.8 2.0

North Jakarta City 400 25 17.3 29.8 52.0 1.0 1.3 21.8 50.3 25.3 1.5

Sukabumi City 400 26 9.8 31.5 57.5 1.3 0.0 15.5 38.5 41.8 4.3

Bekasi City 399 27 7.5 26.3 65.9 0.3 2.0 19.0 37.8 41.1 0.0

Depok City 401 31 6.0 20.4 72.8 0.7 0.7 8.5 29.7 58.4 2.7

Pekalongan City 397 25 8.3 37.3 52.4 2.0 1.0 16.1 30.0 51.1 1.8

Sumenep 400 30,5 2.5 14.8 82.0 0.8 3.5 13.0 13.0 59.8 10.8

Surabaya City 400 29 4.3 21.0 72.5 2.3 2.5 12.3 30.8 51.0 3.5

Gianyar 235 29 11.9 20.4 66.4 1.3 4.7 25.1 39.1 30.2 0.9

Balikpapan City 202 27 2.0 27.7 69.8 0.5 1.5 4.5 23.3 64.9 5.9
Maluku Tenggara 59 28 5.1 30.5 62.7 1.7 1.7 5.1 39.0 54.2 0.0
Barat#
Jayapura City 371 28 4.3 25.1 67.9 2.7 0.5 10.5 32.9 52.0 4.0

Aggregate 5541 27 7.3 27.5 64.0 1.2 1.2 14.3 35.1 46.4 3.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

103
 5.1.3 Level of Education

The highest level of education that FSWs had was defined as the level of education that FSWs
completed, or started but did not complete. As an aggregate, the majority of FSWs completed high
school/equivalent (46.4%), and the smallest proportion was the ones who never went to school
(1.2%) (Table 5.4). In several Districts/Municipalities, most of the FSWs only completed junior
high school/equivalent: Pangkal Pinang City (45.6%), Batam City (46.2%), West Jakarta City
(45.0%) and North Jakarta City (50.3%). Similar to 2018-2019 IBBS finding, the 2015 IBBS found
that the majority of indirect FSWs completed high school (40.9%), but direct FSWs mostly only
finished elementary school/equivalent (40.8%) (MOH, 2015). The 2018-2019 IBBS also found
that 1.2% of FSWs never went to school, while FSWs with low level of education would be at
higher risk of engaging in risky sexual behavior due to lack of knowledge. In contrast, in Sumenep
District, 10.8% of FSWs attended college/university (10.8%).

Aside from economic empowerment, education is one aspect that can provide FSWs a lot of
benefits. Educated FSWs with broad knowledge would be be more empowered and can therefore
contribute more to the society. Empowerment of FSWs is a systematic and continual process that
includes health, human rights and social welfare issues with the aim of achieving behavior change
and providing access to health care in order to reduce the risk of HIV infection (WHO, 2012).

5.1.3 Marital Status

Marital status in the FSW group was defined as a bond of marriage that is officially recognized by
tradition, law or religion. In the FSW group, marital status was categorized into three groups:
unmarried, married (married and living with the spouse, married and living separately from the
spouse), divorced (divorced and widowed).

Table 5.5 Marital Status and Living Arrangement of FSW

Marital Status of Respondents
Living Arrangement (%)
(%)
With other With
District/Municipality n With
women at friends at With
Unmarried Married Divorced Alone the a rental husband/ Other
family
localization place partner

Simeulue# 73 45.2 27.4 27.4 11.0 0.0 35.6 16.4 37.0 0.0

Bukittinggi City# 22 63.6 22.7 13.6 4.5 0.0 68.2 13.6 13.6 0.0

Ogan Komering Ulu (OKU) 370 28.1 14.3 57.6 23.8 14.9 33.5 4.3 20.3 3.2

Pangkal Pinang City 384 21.6 9.6 68.8 9.6 47.4 14.8 4.9 16.7 6.5

Batam City 385 24.2 6.5 69.4 15.8 46.8 18.2 5.2 3.4 10.6

South Jakarta City 397 30.5 28.5 41.1 27.7 1.8 2.5 23.4 44.1 0.5

West Jakarta City 400 30.0 21.0 49.0 38.5 10.0 10.5 16.3 22.8 2.0

North Jakarta City 400 23.5 12.0 64.5 20.5 44.8 10.8 6.5 17.0 0.5

Sukabumi City 400 32.3 20.3 47.5 20.8 0.5 46.5 13.5 17.3 1.5

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 Marital Status of Respondents
Living Arrangement (%)
(%)
With other With
District/Municipality n With
women at friends at With
Unmarried Married Divorced Alone the a rental husband/ Other
family
localization place partner

Bekasi City 399 39.1 15.3 45.6 28.8 8.0 46.1 10.5 6.3 0.3

Depok City 401 38.7 26.4 34.9 30.9 6.7 15.7 8.5 36.9 1.2

Pekalongan City 397 43.6 38.5 17.9 9.3 0.0 13.4 17.6 51.1 8.6

Sumenep 400 22.8 47.3 30.0 13.5 3.3 23.0 29.0 31.3 0.0

Surabaya City 400 27.8 25.8 46.5 46.5 6.3 8.8 18.5 19.3 0.8

Gianyar 235 26.0 7.7 66.4 46.4 9.8 14.9 11.5 8.5 8.9

Balikpapan City 202 27.7 12.9 59.4 29.2 20.8 16.3 7.4 19.3 6.9

Maluku Tenggara Barat# 59 11.9 22.0 66.1 3.4 37.3 35.6 5.1 11.9 6.8

Jayapura City 371 21.8 11.3 66.8 14.8 59.6 14.8 4.9 3.8 2.2

Aggregate 5541 29.4 20.6 50.0 24.4 18.6 19.5 12.4 21.8 3.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Overall, half (50%) of FSW respondents were divorced (Table 5.5), and this situation was seen in
all Districts/Municipalities, except in Pekalongan City where the percentage of divorced FSWs
was only 17.9%. Unmarried FSWs were primarily found in Depok City (38.7%) and Pekalongan
City (43.6%). Unmarried and divorced FSWs are essentially free to work as a sex worker without
restrictions from their spouse, on the other hand, being divorced may push someone to enter the
sex industry to make ends meet, primarily women who had children to provide for.

5.1.4 Living Arrangement

The survey collected information about the residence and living arrangement of FSWs, whether
they had a permanent place to live, and if yes whether they lived alone, or with another individual.
The majority of FSWs (88.3%) had a permanent place to live, 24.4% lived alone, 21.8% stayed
with their family, 19.5% rented a place for themselves and friends, while 18.65% stayed with
friends at the localization (Table 5.5). This living arrangement is of particular importance as it
may influence FSW’s sexual behavior.

The living arrangement of FSWs varied between District/Municipality. The highest percentage of
FSWs who lived with friends in the localization was found in Jayapura City (59.6%), followed by
Pangkal Pinang City (47.4%), Batam City (46.8%), and North Jakarta City (44.8%). Staying at the
localization may increase the possibility for higher sexual risk behavior, but it also provided
health workers more opportunity to reach sex workers with services. Overall, more than a
quarter of FSWs lived with their family, the highest percentage was found in Pekalongan City
(51.0%) and the lowest was in Batam City (3.4%). A small proportion of FSWs (3.3%) lived in
their job’s dormitory.

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 5.1.5 Main Source of Income

In addition to selling sex, the survey identified eight other sources of income for FSWs. A very
small proportion obtained income as field outreach workers, but in analysis the percentage was
combined with other occupation. More than half (65.9%) of FSWs obtained their income from sex
work (Table 5.6). In several Districts/Municipalities, sex work was the main source of income for
the majority of FSWs (>90%). This was identified in Batam City (96.9%), South Jakarta (93.2%)
West Jakarta (90.5%), North Jakarta (95.0%), Surabaya City (97.8%) and Balikpapan City
(91.6%).

Table 5.6 Primary Source of Income among FSW

Primary Source of Income Besides Sex Work (%)

Sex as
Private
primary Sales Entertainer
Company Attendant at
District/Municipality n source of n Domestic Salon Attendant/ (Bar/
Merchant Employee Massage Other
income Assistant Worker Marketing Karaoke
(Bank, other Parlor/ Spa
(%) Staff Bar)
Business)

Simeulue# 73 38.4 45 35.6 28.9 0.0 0.0 0.0 2.2 0.0 33.3

Bukittinggi City# 22 77.3 5 0.0 20.0 20.0 40.0 0.0 0.0 20.0 0.0

Ogan Komering Ulu 37.8 230 2.6 10.9 4.8 7.8 0.9 27.4 37.4 8.3
370
(OKU)
Pangkal Pinang City 384 65.1 134 2.2 6.7 3.0 17.2 0.7 3.7 61.9 4.5

Batam City 385 96.9 12 0.0 0.0 0.0 0.0 8.3 0.0 83.3 8.3

South Jakarta City 397 93.2 27 3.7 3.7 18.5 11.1 3.7 7.4 22.2 29.6

West Jakarta City 400 90.5 38 23.7 0.0 2.6 34.2 0.0 7.9 18.4 13.2

North Jakarta City 400 95.0 20 15.0 0.0 25.0 20.0 5.0 0.0 10.0 25.0

Sukabumi City 400 49.8 201 7.0 6.0 31.3 6.0 7.5 1.5 29.9 10.9

Bekasi City 399 17.5 329 0.3 11.6 9.4 8.8 1.2 27.1 40.4 1.2

Depok City 401 41.1 236 2.1 17.8 20.3 16.1 0.4 17.8 15.3 10.2

Pekalongan City 397 48.6 204 3.9 21.6 28.9 28.9 0.5 1.5 10.3 4.4

Sumenep 400 40.3 239 20.9 9.2 28.0 22.6 11.3 0.0 6.3 1.7

Surabaya City 400 97.8 9 11.1 0.0 11.1 11.1 0.0 11.1 33.3 22.2

Gianyar 235 58.3 98 1.0 2.0 1.0 3.1 0.0 6.1 75.5 11.2

Balikpapan City 202 91.6 17 5.9 5.9 29.4 23.5 11.8 0.0 11.8 11.8

Maluku Tenggara Barat# 59 61.0 23 4.3 0.0 0.0 8.7 0.0 0.0 52.2 34.8

Jayapura City 371 74.1 96 5.2 0.0 2.1 4.2 0.0 13.5 61.5 13.5

Aggregate 5541 65.9 1890 5.7 10.4 16.0 14.0 3.0 12.2 31.6 7.5
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Table 5.6 lists the additional sources of income that FSWs had. The majority worked as
entertainers in bar/karaoke bar (31.6%), also as sales attendant or marketing staff (16.0%), or
merchants/sellers of various goods (14.0%). There were also some who worked in massage
parlor or spa (12.2%) and the rest were either housewives, waitresses, or small business owners,
etc (7.5%). Overall, 3.0% of FSWs were also employees at a bank, or other private companies.

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This data showed that, even though the proportion is small, there were women with a steady
income who worked as sex workers. FSW’s source of income aside from sex work varied between
district/municipality.

The majority of FSWs who worked as domestic assistant was found in West Jakarta (23.7%) while
FSWs who primarily worked in salon were found in Pekalongan City (21.6%). In Sukabumi City,
most FSWs worked as sales attendant or marketing staff (31.3%), while the largest proportion of
FSWs who also worked as sellers of various goods was found in Pekalongan City (28.9%). FSWs
who were private employees (of bank/company/other business) were mostly found in
Balikpapan City (11.8%), and FSWs who worked in massage parlor/spa were primarily found in
Oga Komering Ulu District (27.4%). Lastly FSWs who worked in bars/karaoke bars were mostly
found in Batam City (83.3%). Information about the type of occupation that FSWs had would be
useful to help health providers reach out to the FSW community.

FSWs in the 15-49-year age range mostly worked in bar/karaoke bar at a percentage ranging
from 27.5% to 41.8%, while older FSWs (≥50 years old) mostly worked as merchants (50.0%). A
look at the educational level and type of employment of FSWs revealed that the majority of FSWs
who never went to school earned their income from selling goods (35.7%), while FSWs with some
education, between elementary school to high school, mostly worked in bar/karaoke bar at a
percentage ranging from 25.8%-34.9%. FSWs with higher education typically worked as sales
attendant or marketing staff (35.1%).

5.1.6 Identity Card Ownership and Health Insurance Coverage

Having an identity card is one proof of official citizenship of a country. The 2018-2019 IBBS found
that overall most FSWs had an identity card (94,5%) except in Bekasi City where the percentage
of FSWs with ID card was 73.9% (Table 5.7). The highest percentage was found in Balikpapan
City (99.5%).

Health insurance coverage is one indicator that indirectly gives information about FSW’s access
to health care. More than half (57.7%) of FSWs did not have health insurance (Table 5.7). Those
who did have health insurance coverage were categorized into: government insurance (BPJS),
non-government (private) insurance, and both government and private insurance. The most
common health insurance was BPJS (39.9%) while private insurance was only owned by 1.8%
FSWs. In Districts/Municipalities where a large proportion of FSWs did not yet have health
insurance, the percentage almost reached 50%, such as North Jakarta City (47.8%), Depok City
(37.9%), Pekalongan City (42.1%) and Balikpapan City (43.1%). All the sites with less than 50%
health insurance coverage for FSWs were urban areas. The highest proportion of FSW coverage
by BPJS was found in Depok City (57.7%) and Pekalongan City (57.9%) while the lowest was
found in Gianyar District (16.2%). The highest proportion of private insurance was found in
Surabaya City (5.8%).

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 Table 5.7 Identity Card Ownership and Health Insurance Coverage of FSW

Net Monthly Income from Sex

Work * Health Insurance Coverage (%)
Own Identity
Non- Both
District/Municipality n Card Government
(%) Median High Low Government Government
Insurance None
(Rp) (%) (%) Insurance and Private
(BPJS)
(Private) Insurance
Simeulue# 73 90.4 1,000,000 13.6 86.4 94.5 0.0 0.0 5.5

Bukittinggi City# 22 95.5 4,000,000 95.5 4.5 31.8 31.8 0.0 36.4

Ogan Komering Ulu (OKU) 370 97.0 3,800,000 80.2 19.8 18.4 0.5 1.9 79.2

Pangkal Pinang City 384 95.3 3,500,000 76.8 23.2 39.6 1.3 0.3 58.9

Batam City 385 95.1 7,000,000 93.7 6.3 32.7 1.0 0.3 66.0

South Jakarta City 397 97.5 5,000,000 92.0 8.0 48.1 1.5 0.0 50.4

West Jakarta City 400 95.5 5,000,000 85.4 14.6 43.8 3.0 1.0 52.3

North Jakarta City 400 91.0 3,000,000 77.8 22.2 47.5 2.0 2.8 47.8

Sukabumi City 400 94.8 3,000,000 63.9 36.1 40.5 2.5 0.3 56.8

Bekasi City 399 73.9 5,000,000 91.6 8.4 31.6 0.3 0.3 67.9

Depok City 401 94.8 6,000,000 91.1 8.9 57.6 1.0 3.5 37.9

Pekalongan City 397 98.7 4,000,000 90.2 9.8 57.9 0.0 0.0 42.1

Sumenep 400 99.3 2,500,000 53.5 46.5 30.8 2.5 4.5 62.3

Surabaya City 400 98.3 6,000,000 89.3 10.8 28.5 5.3 0.5 65.8

Gianyar 235 94.0 3,000,000 64.7 35.3 16.2 1.3 0.0 82.6

Balikpapan City 202 99.5 5,500,000 94.6 5.4 52.0 3.5 1.5 43.1

Maluku Tenggara Barat# 59 94.9 4,000,000 76.3 23.7 42.4 1.7 1.7 54.2

Jayapura City 371 95.4 5,000,000 80.1 19.9 39.4 1.3 1.1 58.2

Aggregate 5541 94.5 4,000,000 81.4 18.6 39.3 1.8 1.2 57.7

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Missing data had
been taken out

In Pekalongan City, no FSWs had private health insurance. The highest proportion of FSWs with
both BPJS and private insurance was found in Sumenep District (4.5%). Table 5.7 shows that the
percentage of FSWs with BPJS was still very small (39.3%) while health insurance coverage
correlated with health care access. It indirectly provided some indication about FSW’s access to
health care. In this study, 57.7% of FSWs did not yet have any health insurance (Table 5.7).

5.1.7 Monthly Income from Sex Work

One reason a woman may decide to enter the sex industry is economic factor, so the amount of
income that is received from sex work may affect one’s decision to continue working as a sex
worker. The higher the income, the more likely a sex worker will continue her profession. As

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shown in Table 5.7, the median monthly income from sex work was Rp. 4,000,000, but FSWs in
more than half of the Districts/Municipalities had a higher median monthly income than the
aggregate number. The highest median income, at Rp. 7,000,000 was found in Batam City and the
lowest at Rp. 2,500,000 was found in Sumenep District. Three sites (Simeulue District, Bukittinggi
City and Maluku Tenggara Barat District) had very few samples and data from those sites were
considered as unable to represent the FSW income in the respective District/Municipality.

The monthly income FSWs received from selling sex was categorized into high and low based on
the average national wage in 2018. The 2018 average national wage was calculated from the
average national wage in 2016 of Rp. 1,997,819 (BPS, 2016) plus 8.25% increase for year 2017
and an additional increase of 8.71% for year 2018 to arrive at Rp. 2,351,005 for the average
national wage for 2018. High income was defined as equal or higher than the 2018 average
national wage (≥ Rp. 2,351,005) and low income was defined as lower than the 2018 average
national wage (<Rp. 2,351,005). Based on this categorization, 81.4% of FSWs would fall into the
high-income category. The highest proportion was found in Balikpapan City (94.6%) and the
lowest proportion was in Sumenep District (53.5%). Sex workers actually did not consider their
work as a quick way to obtain money, but the work also provided them with some financial
benefit that could improve their economic status or enable them to provide for their family.
(Worcester, 2002).

5.1.8 Sex Transaction Venue in the Last Year

The venue of paid sex transaction in the last year demonstrated the work location of FSWs in the
last year (Table 5.8). The most common venue was karaoke bar (37.1%) followed by massage
parlor (24.5%) and hotel/motel/cottage (21.4%). The smallest percentage was by the
roadside/railway track (9.1%). With regards to each District/Municipality, karaoke bar was the
most common sex transaction venue in Sukabumi City (70.3%) and the least common venue in
Gianyar District (17.9%). In Jakarta City, no FSWs conducted sex transaction in a localization
within the past year.

Table 5.8 FSW Sex Transaction Venue in the Last Year

Venue of Paid Sex Transaction in the Last Year (%)

District/Municipality n Roadside/
Karaoke Massage Bar/ Restaurant/ Hotel/Motel/
Railway Localization Other
Bar Parlor Discotheque Food Stall Cottage
Track
Simeulue# 73 56.2 23.3 1.4 9.6 0.0 0.0 53.4 13.7

Bukittinggi City# 22 45.5 0.0 13.6 0.0 0.0 4.5 68.2 0.0

Ogan Komering Ulu (OKU) 370 28.4 27.8 4.1 5.7 0.0 5.1 23.5 4.3

Pangkal Pinang City 384 30.5 13.0 15.4 9.4 1.8 32.8 14.1 2.3

Batam City 385 33.8 11.4 42.1 0.3 0.3 46.5 29.6 0.0

South Jakarta City 397 44.1 37.0 3.5 0.0 2.5 0.0 17.9 1.8

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 Venue of Paid Sex Transaction in the Last Year (%)
Roadside/
District/Municipality n Karaoke Massage Bar/ Restaurant/ Hotel/Motel/
Railway Localization Other
Bar Parlor Discotheque Food Stall Cottage
Track
West Jakarta City 400 21.3 51.5 12.3 0.5 1.0 5.0 2.5 2.5

North Jakarta City 400 37.0 15.3 35.0 3.0 0.5 17.5 2.8 1.0

Sukabumi City 400 70.3 10.3 28.0 26.0 26.0 5.5 29.5 5.0

Bekasi City 399 66.9 42.1 51.9 3.0 4.0 14.0 27.1 3.3

Depok City 401 24.4 27.7 9.0 21.7 9.5 0.2 20.7 19.0

Pekalongan City 397 51.6 10.8 12.8 42.6 40.6 1.5 20.4 0.3

Sumenep 400 23.0 5.3 2.0 44.5 30.5 13.3 79.5 5.8

Surabaya City 400 31.3 52.8 8.0 0.5 6.8 0.5 0.8 1.5

Gianyar 235 17.9 10.6 27.2 12.8 0.0 1.7 10.6 22.1

Balikpapan City 202 55.0 8.9 28.2 0.0 0.0 5.9 17.8 0.0

Maluku Tenggara Barat# 59 33.9 0.0 1.7 0.0 0.0 5.1 11.9 23.7

Jayapura City 371 20.8 28.8 21.8 1.3 3.0 7.8 17.8 4.3

Aggregate 5541 37.1 24.5 19.6 11.9 9.1 10.8 21.4 4.6
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Missing data had
been taken out

Localization was the most common sex transaction venue in Batam City (46.5%). In Pekalongan
City and Sumenep District, almost half of FSWs (42.6% and 44.5% respectively) carried out their
sex transaction in a food stall/restaurant in the last year. Venue of sex transaction could indirectly
indicate the class or level of FSWs and the likely amount of payment they received from sex work.
More of FSWs who carried out their sex transaction in a food stall/restaurant and by the
roadside/railway track had income below the national average wage than FSWs with sex
transaction in karaoke bar, massage parlor, bar/discotheque, localization and hotel/motel
(35.5% and 40.4%).

5.1.9 Client’s Occupation in the Last Year

Clients of FSW came from various occupational background. The question about client’s
occupation in the last year was a multiple-answer question, so FSWs could select more than one
answer. Overall, clients were mostly merchants (39.0%) (Table 5.9), the highest proportion of
clients as merchant was found in Bekasi City (67.2%). The second most common occupation was
were driver (35.3%), Civil Servant (33.1%), or police officer (31.5%). Drivers were also one
population group who are at risk of HIV infection and are categorized as high-risk men (HRM).

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 Table 5.9 Occupation of FSW’s Client in the Last Year
Occupation of Clients in the Last Year (%)
District/Municipality n Student/ Police/ Truck Motorcycle
Civil
Univ. Army Driver Driver Ship Crew Taxi Merchant Other Unemployed
Servant
Student Member Assistant Driver
Simeulue# 73 52.1 32.9 47.9 54.5 11.0 1.4 15.1 34.2 0.0 9.6

Bukittinggi City# 22 54.5 68.2 68.2 40.5 27.3 0.0 31.8 77.3 13.6 0.0

Ogan Komering Ulu 370 13.8 20.3 25.7 41.4 18.9 0.8 15.1 23.8 17.0 3.0
(OKU)
Pangkal Pinang City 384 7.0 21.6 25.5 15.8 11.5 26.8 11.2 44.8 27.9 8.1

Batam City 385 5.7 24.4 22.6 9.3 6.2 68.6 10.4 35.1 5.2 2.9

South Jakarta City 397 10.1 28.5 25.4 34.3 1.0 1.8 4.0 14.9 70.0 0.3

West Jakarta City 400 34.3 33.3 29.8 45.3 8.0 20.0 19.3 61.0 24.3 1.3

North Jakarta City 400 19.3 43.0 25.3 29.5 18.5 60.0 16.8 30.8 20.0 1.5

Sukabumi City 400 30.8 44.3 53.3 64.9 0.8 1.0 8.0 49.0 19.8 4.5

Bekasi City 399 33.3 20.1 42.9 42.4 15.0 42.4 18.5 67.2 33.3 6.0

Depok City 401 33.9 46.6 48.1 22.2 6.2 1.5 17.5 29.9 36.4 0.2

Pekalongan City 397 11.3 2.0 0.0 67.5 10.8 18.6 8.1 16.1 44.8 0.0

Sumenep 400 37.5 38.5 43.0 29.3 51.5 34.3 42.0 54.0 0.25 9.8

Surabaya City 400 47.5 50.0 53.8 44.7 11.8 21.3 18.3 54.5 26.5 1.8

Gianyar 235 29.8 26.4 24.3 15.8 18.7 1.7 8.5 26.4 20.9 3.4

Balikpapan City 202 18.3 55.4 35.6 8.5 4.0 52.0 4.5 47.0 32.7 1.5

Maluku Tenggara 59 3.4 44.1 25.4 19.9 1.7 23.7 8.5 16.9 20.3 5.1
Barat#
Jayapura City 371 6.5 26.1 37.7 54.5 1.6 4.9 12.1 31.0 18.6 12.7

Aggregate 5541 22.8 31.5 33.1 35.3 12.5 23.4 14.8 39.3 26.6 3.8
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

This result showed that clients of FSW were of various professions, from those who had a steady
job to those who were unemployed or even students (22.8%). With student clients, sexual
transaction typically occurred in rental rooms, at a cemetery or in cafés, while merchant clients
would have the sex transaction at various places at equal proportion.

5.2 Virtual Network

This section discusses the exposure that FSWs had to online media, particularly media that were
related to sexual activities or provide information on HIV prevention and transmission. Questions
that relate to virtual network were asked to FSW respondents to gain a picture about their
internet access and use of online media.

The majority of FSWs had access to the internet (82.3%). In most Districts/Municipalities where
the survey was conducted, more than 70% of respondents accessed the internet (Table 5.10).
Internet use included social media like Facebook, Twitter, WA (WhatsApp), Path, Instagram, and

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 others. A small proportion of FSWs also visited sex worker-related websites (3.8%) and joined an
FSW mailing list (6.2%). An equally small number of FSWs used the internet to search for
information on HIV prevention and transmission (5.3%) or did so in the last month (4.4%). This
showed that eventhough the majority of FSWs had access to the internet, very few had concerns
or tried to find information about HIV prevention and transmission eventhough with the rapid
development of technology, access to information has actually become easier.

Availability of social media has had both positive and negative impact on the FSW group. On one
hand social media allowed FSWs to easily access information on illness or health, but on the other
hand FSWs used social media to connect with potential clients, expand their sexual network or
engage in online prostitution, all of which increased their risk for HIV/AIDS and STI infection.

Rapid development of the internet has made it possible for individuals to communicate with one
another without direct face-to-face meeting. Through the internet, one can communicate and get
introduced to a new person, carry out discussions, find partners, including dating partners or
clients in the case of sex workers. FSWs stated that the internet enabled them to find clients more
safely, and easily. They would not need to stay at one spot waiting for clients, so this approach
gave them time flexibility. In addition, FSWs also did not need to have a pimp to act as their boss.

Currently, numerous applications or online/social media are used by FSWs to communicate and
find clients. These included Facebook, Twitter, Path, Instagram and mIRC (Internet Relay Chat).
The most commonly used social media were Facebook and Instagram, while group chats that
FSWs commonly used were Chery, My Chat, etc.

Table 5.10 Internet Access, Information Search, Online Communication and Exposure to Social Media among FSW

Did Internet Search for Communicated Online

Access the Visit FSW- Join FSW Mailing Information on HIV Prevention about HIV Prevention and
District/Municipality n Internet related List and Transmission on FSW in Transmission in the Last
(%) Websites (%) (%) the Last Month Month
(%) (%)
Simeulue# 73 2.8 2.7 0.0 0.0 0.0

Bukittinggi City# 22 90.9 13.6 9.1 18.2 9.1

Ogan Komering Ulu (OKU) 370 79.7 3.0 0.5 4.6 1.9

Pangkal Pinang City 384 76.3 0.8 0.8 4.2 1.8

Batam City 385 82.1 11.2 1.0 9.4 5.2

South Jakarta City 397 67.3 5.8 17.1 4.5 5.5

West Jakarta City 400 85.5 5.3 8.5 6.5 2.3

North Jakarta City 400 88.8 5.3 6.8 9.5 3.8

Sukabumi City 400 88.0 0.3 2.0 0.3 0.0

Bekasi City 399 83.0 5.3 2.3 1.3 1.0

Depok City 401 91.5 0.5 0.0 3.5 2.0

Pekalongan City 397 97.5 0.0 17.6 10.8 11.1

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 Did Internet Search for Communicated Online
Access the Visit FSW- Join FSW Mailing Information on HIV Prevention about HIV Prevention and
District/Municipality n Internet related List and Transmission on FSW in Transmission in the Last
(%) Websites (%) (%) the Last Month Month
(%) (%)
Sumenep 400 86.8 5.3 12.8 1.3 1.3

Surabaya City 400 78.5 1.5 7.0 5.3 10.5

Gianyar 235 63.8 2.1 1.7 7.2 2.1

Balikpapan City 202 79.2 0.5 1.5 5.9 1.0

Maluku Tenggara Barat# 59 88.1 6.8 11.9 10.2 5.1

Jayapura City 371 77.1 7.5 7.0 5.4 2.7

Aggregate 5541 82.3 3.8 6.2 5.3 4.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

5.3 Knowledge about HIV/AIDS, Its Risk, and Prevention

Knowledge is the result of “knowing” and this occurs after an individual experiences a certain
object through their senses; seeing, smelling, hearing, touching. Cognitive knowledge
predominantly shapes someone’s action (Notoatmodjo, 2007). The more information a person
receives, the more knowledge he/she has. Therefore, as a high-risk group for HIV/AIDS, it is
important for FSWs to know about HIV/AIDS. Good knowledge is hoped to influence their sexual
practices, and enable them to adopt protective behaviors. Information on HIV/AIDS that is
provided to FSWs include topics on HIV/AIDS prevention, misconceptions, and risk perception.

5.3.1 Previous Exposure to HIV/AIDS Information and Source of Information

Exposure to HIV/AIDS information is one critical factor that determines FSW’s level of knowledge.
Overall 61.2% of FSWs had received information on HIV/AIDS in the past (Table 5.11), a far lower
proportion than FSWs in India whose 2014-2015 IBBS recorded a 94.5% exposure to information
(National AIDS Control Organization, 2015). In Indonesia, FSW’s exposure to information also
varied between districts, from 15.1% to 88.1%. The highest was in Jayapura City (84.4%) and the
lowest was among FSWs in Bekasi City and Ogan Komering Ulu (OKU) District (36.4%).

The survey also asked respondents’ sources of information, and more than half (53.0%) of FSWs
stated health workers as their source. This situation was similar in most Districts/Municipalities,
except in Oga Komering Ulu District (19.1%), Bekasi City (24.5%), and Pekalongan City (24.3%).
More than a quarter of FSWs (28.2%) cited television as their source of HIV/AIDS information
(Table 5.11), and the highest was in Ogan Komering Ulu (OKU) District (65.4%). Field outreach
workers, and cadres were also important sources of information (25.9%), except in Oga Komering
Ulu District where the proportion was zero. Internet, social media, website/blog was cited as a
source of information for a third of FSWs in Pekalongan City (29.0%). This finding is in line with

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 the result of a cross-tabulation analysis on social media use among FSWs. In Pekalongan City, the
proportion of HIV/AIDS information search through social media was the highest.

Table 5.11 Source of HIV/AIDS Information among FSW

Received Source of Information among Respondents who Had Received Information (%)
Information
Poster/ Field Outreah Social or
District/Municipality n about Newspaper/ Health
HIV/AIDS Radio TV Leaflet/ Worker/Cadre Peers Pimp Online Other
Magazine Worker
(%) Booklet / Educator Media

Simeulue# 73 15.1 0.0 27.3 9.1 0.0 90.9 0.0 9.1 0.0 0.0 0.0

Bukittinggi City# 22 45.5 10.0 20.0 10.0 0.0 90.0 50.0 40.0 0.0 50.0 30.0

Ogan Komering Ulu (OKU) 370 36.8 2.9 65.4 11.0 9.6 19.1 0.7 19.1 0.7 36.8 2.2

Pangkal Pinang City 384 42.4 3.7 13.5 4.3 5.5 73.6 12.9 9.2 0.0 5.5 0.0

Batam City 385 80.8 4.5 37.0 7.1 5.8 42.8 41.5 20.6 0.6 16.7 2.6

South Jakarta City 397 69.5 0.0 25.0 16.3 8.0 43.8 39.9 3.6 0.0 9.1 3.6

West Jakarta City 400 77.0 8.8 28.2 11.4 6.5 73.7 25.6 13.0 0.0 27.6 8.8

North Jakarta City 400 68.5 0.0 9.9 1.8 6.9 70.1 38.7 4.4 0.0 5.5 1.5

Sukabumi City 400 45.3 0.6 14.9 3.3 30.4 64.1 59.7 0.6 0.0 1.7 0.6

Bekasi City 399 36.8 5.4 52.4 29.9 51.7 24.5 19.7 15.6 0.7 10.9 8.2

Depok City 401 48.9 5.6 30.1 19.4 14.8 36.2 26.5 18.9 1.0 15.3 4.1

Pekalongan City 397 64.2 0.4 31.8 0.8 2.7 24.3 2.7 38.4 0.0 29.0 2.0

Sumenep 400 68.0 19.9 44.1 27.9 25.7 39.0 14.0 46.7 0.0 14.0 1.8

Surabaya City 400 65.0 1.2 21.5 12.7 2.3 55.8 36.5 10.0 0.4 11.9 4.6

Gianyar 235 71.5 3.6 23.2 8.9 1.2 63.1 11.3 16.7 0.0 9.5 4.8

Balikpapan City 202 64.9 1.5 9.2 15.3 10.7 51.9 23.7 6.1 0.0 9.2 3.8

Maluku Tenggara Barat# 59 88.1 1.9 30.8 5.8 7.7 73.1 15.4 7.7 1.9 7.7 3.8

Jayapura City 371 84.4 5.4 24.3 5.4 7.3 85.3 17.3 10.5 0.0 15.0 9.3

Aggregate 5541 61.2 4.5 28.2 11.2 11.3 53.0 25.9 16.2 3.2 14.5 4.3
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Health provider/worker and field outreach worker played a key role in disseminating HIV/AIDS
information to FSWs, in addition to electronic media like TV and social media. Other sources of
information were cited by some FSWs (4.3%). These included case manager, counselor, special
event/infotainment, hotline service/text messaging service. Another finding was that some FSWs
stated they had never received information on HIV/AIDS. Analysis showed that 80.8% of FSWs
who had received HIV/AIDS information attended higher education (college/university level),
and 65.3% were FSWs who completed high school/equivalent. Higher level of education
increased one’s opportunity to receive or be exposed to information.

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 5.3.2 Knowledge about HIV/AIDS

Knowledge is linked to an individual’s attitude and practices, eventhough good knowledge does
not necessarily mean the individual will adopt good practices. It is expected that FSWs with good
HIV/AIDS knowledge will practice good sexual behavior. This survey then looked at FSW’s
knowledge about HIV/AIDS prevention, and related misconceptions that overall were defined as
comprehensive knowledge.

Table 5.12 FSW’s Knowledge about HIV/AIDS, Its Risk and Prevention

Knowledge about HIV (%) Protective Behavior to

Prevent HIV
Prevention of HIV Transmission of HIV (%)
A healthy-
looking HIV is not Comprehensive Risk
District/Municipality n HIV is not Knowledge Perception
individual transmitted
transmitted (%)* (%) Always Be faithful Not
can be Always use Be faithful through
HIV- through use to sex sharing
condom to partner sharing
infected mosquito/ condom partner needle
eating
insect bite
utensils
Simeulue# 73 15.1 13.7 15.1 15.1 12.3 2.7 11.0 38.4 52.1 57.5

Bukittinggi City# 22 31.8 45.5 40.9 27.3 40.9 4.5 86.4 77.3 31.8 9.1

Ogan Komering Ulu (OKU) 370 30.0 65.1 71.1 45.4 46.2 16.8 33.8 57.8 52.7 43.8

Pangkal Pinang City 384 30.2 54.2 55.2 47.1 42.4 15.4 62.8 80.5 48.2 40.1

Batam City 385 66.2 68.3 57.4 58.2 50.4 22.6 87.0 95.6 45.5 31.9

South Jakarta City 397 39.5 73.3 71.8 64.2 57.7 17.9 85.1 97.0 55.2 50.4

West Jakarta City 400 34.5 76.8 71.3 47.0 41.0 8.0 77.8 96.0 68.0 50.3

North Jakarta City 400 35.5 62.3 62.0 48.3 43.3 11.0 73.5 85.3 71.8 60.8

Sukabumi City 400 22.8 61.5 56.5 32.8 36.5 9.3 77.5 82.0 23.3 17.5

Bekasi City 399 12.3 39.3 41.1 30.1 23.6 4.0 52.4 83.5 41.4 23.3

Depok City 401 28.9 60.1 58.1 52.1 49.6 10.2 56.4 71.6 44.1 52.4

Pekalongan City 397 74.6 82.1 79.8 66.0 40.8 29.0 72.3 86.4 36.3 34.8

Sumenep 400 66.8 78.5 73.3 61.3 58.3 43.8 23.8 87.0 57.3 63.0

Surabaya City 400 44.5 73.0 60.8 40.8 36.3 8.0 74.5 86.0 35.8 54.3

Gianyar 235 40.0 68.9 66.0 48.9 47.2 7.7 53.6 74.9 53.2 32.3

Balikpapan City 202 44.6 59.9 57.4 45.5 54.5 12.9 78.2 84.2 72.8 38.1

Maluku Tenggara Barat# 59 45.8 74.6 78.0 49.2 52.5 11.9 39.0 76.3 78.0 45.8

Jayapura City 371 52.0 86.5 72.5 63.6 68.5 19.4 76.3 90.6 66.6 49.1

Aggregate 5541 41.4 67.5 63.7 50.2 46.0 16.0 65.6 84.2 50.6 43.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *A Composite of
FSWs who knew about HIV/AIDS prevention (always use condom in sexual intercourse and be faithful to one’s partner); about HIV
transmission (HIV is not transmitted through mosquito/insect bite or through sharing eating utensils); about a healthy-looking
individual can be HIV-infected.

FSWs were considered as having comprehensive knowledge based on three types of assessment.
First, they knew about HIV/AIDS prevention (always using condom in sexual intercourse and
being faithful to their partner). Second, they knew about HIV transmission (HIV is not transmitted

115
through mosquito/insect bite or by sharing eating utensils) and FSWs were able to state the
correct answer. Third, FSWs knew that someone who looks healthy can be infected with HIV. The
survey found that level of comprehensive knowledge about HIV/AIDS among FSWs was still very
low (16.0%) (Table 5.12), the lowest was in Bekasi City (4.0%) and the highest was in Sumenep
District (43.8%). The type of HIV/AIDS prevention information that FSWs knew the most was the
condom use (67.5%) and being faithful to one’s partner (63.7%), while the least known
information was about how a healthy-looking individual can actually be HIV-infected (41.1%).

Districts/Municipalities with the highest level of knowledge for HIV/AIDS prevention were
Pekalongan City (82.1% knew about condom use, and 79.2% knew about being faithful to one’s
partner) and Jayapura City (86.5% and 72.5% respectively for the two types of information). The
highest proportion of FSWs with correct knowledge about the misconceptions on HIV
transmission was found in Jayapura City (63.6% knew mosquito/insect bite does not transmit
HIV, and 68.3% knew that sharing eating utensils does not transmit HIV), while the lowest was
found in Bekasi City (30.1% and 23.6% respectively for the two types of information).

5.3.3 Risk Perception for HIV Infection and Protective Behavior

As much as 65.6% of FSWs felt they were at risk of getting HIV, the highest was in Batam City
(87.0%) and the lowest was in Sumenep District (23.8%). Condom use was the most common
protective behavior adopted (84.2%), followed with being faithful to one’s partner (50.6%) and
not sharing non-sterile injection needles (43.3%). The highest proportion of FSWs who used
condom consistently was found in South Jakarta City (97.0%) and the lowest was found in Ogan
Komering Ulu District (57.8%), while being faithful to one’s partner was most adopted by FSWs
in Balikpapan City (72.8%) but least adopted by FSWs in Sukabumi City (23.3%). The highest
proportion of FSWs who avoided needle sharing was found in Sumenep District (63.0%) and the
lowest was found in Sukabumi City (17.3%). In several Districts/Municipalities, the proportion
of protective behavior (condom use and being faithful to one’s partner) among FSWs was actually
higher than the level of knowledge about HIV prevention, for example in North Jakarta City,
Bekasi City and Balikpapan City (Table 5.12).

5.4 Sexual Behavior and Prevention

FSWs are one group who face a high risk of HIV infetion. As people who engage in high-risk
behavior, FSWs can get infected with HIV as well as transmit the infection to other people,
including their clients. As stated in the Decree of the Coordinating Minister for People's Welfare
Number 9/1994, one target for HIV/AIDS information, education and communication (IEC) was
high-risk groups, namely people whose occupation caused them to be at higher risk of getting and
transmitting HIV, and sex workers or FSWs are one example.

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It is really important that FSWs take early precautions against HIV to avoid a chain of
transmission from FSWs to their clients, to clients’partner or family, other sex partner, other
people and other FSWs. This survey collected information about several variables surrounding
FSW’s sexual behavior, consisting of age at first vaginal sex, first anal sex, first selling sex, age
FSWs expected to stop selling sex, length of time in the sex industry, any steady and non-steady
partner, number of clients in the last week and protective behavior adopted in the form of
consistent condom use with client, with steady and non-steady partner.

Up till now efforts to prevent sexual transmission of HIV have been constrained by lack of
guaranteed government funding for condom provision, compounded by insufficient policy
support, people’s reservation of condom as an HIV prevention method, and limited promotion
about condom use among the public (National AIDS Commission - KPAN, 2010).

5.4.1 Sexual Partner and Condom Use Consistency

The risk for STI and HIV/AIDS among FSWs increases with each additional sex partner they have,
and FSWs had three types of sex partners: client or customer, steady partner and non-steady
partner. Clients are sex partners who give payment in the form of money or goods. A steady
partner is a man who FSWs acknowledge or consider as a willing sex partner in a committed
relationship that has lasted for at least three months.

A non-steady partner is a male sex partner who FSWs acknowledge or consider as a willing sex
partner without any specific relationship or commitment, and without any exchange of money or
goods. The survey looked at condom use and its consistency with each type of partner, during the
last sexual encounter and throughout the previous month. The survey also looked at the number
of clients FSWs served in the last week, and reasons for not using condom in the last sex with a
client. Eventhough condom cannot 100% prevent STI and HIV/AIDS infection, it can reduce the
risk of infection. An individual’s sexual behavior, including condom use, is influenced by a number
of factors. Green theorizes that the most important thing in health behavior is shaping changes in
behavior. According to Green, an individual’s behavior change depends on three factors that each
gives a different type of influence: predisposing factor, enabling factor and reinforcing factor
(Green et al., 2002).

Factors that predispose condom use among FSWs and their client are knowledge of STI and
HIV/AIDS and FSW’s attitude toward condom use. Enabling factors include access to information
about STI and HIV/AIDS, while reinforcing factors are client’s perception of safe sex and support
from pimps for condom use (Budiono, 2012).

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 5.4.1.1 Sexual Behavior and Condom Use Consistency with a Steady Partner
As an aggregate, less than half of FSWs (41.1%) had a steady partner, but the proportion varied
between sites. Districts where more than 50% of FSWs had a steady partner were Gianyar District
(66.8%), West Jakarta City (57.0%), Surabaya City (56.3%), Balikpapan City (55.4%) and
Sumenep District (55.3%). The lowest proportion of steady partner was found among FSWs in
Batam City (19.5%) (Table 5.13).

FSWs who had a steady partner were then asked about condom use during their last sex
encounter, also about consistency in condom use in the last month.

Overall, in the last sex with a steady partner, condom was used 22.9% of the time, while in the
last month, condom was consistently used only 15.5% of the time. The highest use of condom was
in Batam City (41.3%) and the most consistent use was found in Pangkal Pinang City (35.1%).

Table 5.13 FSW’s Sexual Behavior and Consistent Condom Use with Steady and Non-Steady Partner
Condom Use among FSWs who
Condom Use among FSWs who Average # Have a Non-Steady Partner
Have a Steady Partner (%) Have a Non- of Non- (%)***
Have a Steady
Steady Steady
District/Municipality n Partner
Used condom Consistently used Partner Partner in Used condom Consistently used
(%)
during last condom in the last (%) the Last during last condom in the last
sex* month** Month sex month

Simeulue# 73 26.0 0.0 0.0 20.8 4 13.3 13.3

Bukittinggi City# 22 36.4 0.0 0.0 63.6 7 85.7 92.3

Ogan Komering Ulu (OKU) 370 30.8 14.0 12.2 53.2 5 40.6 55.2

Pangkal Pinang City 384 29.7 38.6 35.1 36.2 4 62.6 64.9

Batam City 385 19.5 41.3 24.5 57.4 10 84.6 86.2

South Jakarta City 397 45.1 29.6 15.6 18.9 4 81.3 81.3

West Jakarta City 400 57.0 28.9 17.0 40.5 12 77.8 81.8

North Jakarta City 400 33.3 23.3 13.2 20.0 2 40.0 46.4

Sukabumi City 400 43.0 19.2 5.6 42.5 12 47.1 50.3

Bekasi City 399 22.8 9.9 0.0 8.8 6 22.9 28.6

Depok City 401 31.4 19.0 15.4 80.0 2 72.3 73.0

Pekalongan City 397 38.0 15.2 11.7 15.6 5 90.3 93.3

Sumenep 400 55.3 22.2 18.5 45.3 7 61.9 70.9

Surabaya City 400 56.3 16.4 12.2 10.8 6 37.2 38.1

Gianyar 235 66.8 31.2 23.1 30.2 5 88.7 88.7

Balikpapan City 202 55.4 10.7 11.0 35.1 2 32.4 33.3

Maluku Tenggara Barat# 59 61.0 19.4 12.5 30.5 1 33.3 40.0

Jayapura City 371 48.0 25.3 17.6 17.5 5 81.5 84.1

Aggregate 5541 41.1 22.9 15.5 34.2 9 64.2 57.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among FSWs who
had a steady partner; **Among FSWs who had sex with their steady partner in the last month; ***Among FSWs who had a non-steady
partner.

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5.4.1.2 Sexual Behavior and Condom Use Consistency with Non-Steady Partner
Overall, 34.2% of FSWs had a non-steady partner, lower than the proportion of those with a
steady partner. The highest was among FSWs in Depok City (80.0%) and the lowest was in Bekasi
City (8.8%). In each District/Municipality the proportion of FSWs with non-steady partners was
below 50%. Among those who did have a non-steady partner, the highest proportion of condom
use (in the last sex and consistent use in the last month) was found in Pekalongan City (90.3%
and 93.3% respectively).

5.4.1.3 Sexual Behavior and Condom Use Consistency with Client

All survey sites had FSWs who served clients in the last week (Table 5.14). Overall the proportion
was 88.7%, but for each district, the proportion varied. The highest proportion of FSWs who had
clients in the last week was in Pekalongan City (99.5%) and the lowest was in Ogan Komering Ulu
District (46.1%). Condom during the last sex with a client was used by 66.8% FSWs, and among
those who sold sex in the last week, only 67.6% consistently used condom. Eventhough this
percentage was low, it was higher than the percentage of condom use with steady or non-steady
partners. The lowest use of condom was found in Ogan Komering Ulu District (35.9% in the last
sex and 39.5% in consistency) while the highest percentage was found in South Jakarta City
(95.5% used condom in the last sex and 96.0% used it consistently).

5.4.2 Number of Clients in the Last Week

On average, FSWs who sold sex in the last week had four clients. This meant that on average FSWs
served 0 to 1 client per day (Table 5.14), and in one week an FSW would have at least 1 client,
and at the most 5 clients. Five was the median weekly number of clients in half of the
Districts/Municipalities that were surveyed.

In the survey, the number of clients in the last week was grouped into four categories: ≤1 client,
2-4 clients, 5-9 clients and ≥10 clients (Table 5.14). Overall, half of FSWs (49.9%) had 2-4 clients
in the last week. The proportion of FSWs with ≤1 client and ≥10 clients was almost equal at 10.1%
and 9.4% respectively. The highest proportion of FSW with ≤1 client in the last week was found
in Ogan Komering Ulu District (58.8%). The highest proportion of FSW with ≥10 clients in the last
week was found in West Jakarta City (29.5%). Condom use during the last sex in West Jakarta
was quite high (84.0%) and quite consistent in the last month (89.6%), but since the number of
clients was also high, the risk for STI and HIV/AIDS infection remained high.

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 Table 5.14 Sexual Behavior, Consistency in Condom Use with Clients and Number of Clients in the Last Week

Number of Clients in the Last Week

Condom Use (%)
Average (%)*
Sold Had Clients
Number of
Sex in the in the Last Used condom Consistently
District/Municipality n Clients in
Last Week Week in the last sex used condom the Last ≤1 2-4 5-9 ≥ 10
(%) (%) among all in the last
Week
FSWs week*

Simeulue# 73 34.2 35.6 4.1 8.0 2 64.4 15.1 20.5 0.0

Bukittinggi City# 22 81.8 81.8 72.7 72.2 3 27.3 36.4 27.3 9.1

Ogan Komering Ulu (OKU) 369 41.1 46.1 35.9 39.5 2 58.8 19.5 17.9 3.8

Pangkal Pinang City 384 70.8 78.1 56.5 50.7 4 26.8 38.8 29.4 4.9

Batam City 385 93.2 92.7 91.7 89.1 5 11.9 36.9 39.2 11.9

South Jakarta City 397 91.9 95.5 96.0 85.8 5 8.3 51.6 30.0 10.1

West Jakarta City 400 74.5 93.0 84.0 89.6 8 9.8 21.3 38.5 30.5

North Jakarta City 400 79.5 96.5 74.3 69.5 8 7.3 30.5 36.3 26.0

Sukabumi City 400 84.5 88.5 57.8 53.6 3 13.3 66.3 19.8 0.8

Bekasi City 399 88.5 90.0 75.4 71.4 4 10.8 62.9 25.3 1.0

Depok City 401 91.8 95.0 77.3 78.0 5 9.5 34.4 43.6 12.5

Pekalongan City 397 99.5 99.5 67.5 65.6 5 1.3 45.8 47.4 5.5

Sumenep 400 82.8 91.0 33.0 36.6 6 16.3 26.8 44.8 12.3

Surabaya City 400 89.8 99.0 63.5 65.5 7 1.8 25.5 44.0 28.8

Gianyar 235 72.8 90.6 66.0 66.7 5 13.2 26.4 45.1 15.3

Balikpapan City 202 67.3 79.7 36.6 24.3 4 24.8 37.6 35.6 2.0

Maluku Tenggara Barat# 59 13.6 20.3 23.7 25.0 1 86.4 10.2 3.4 0.0

Jayapura City 371 67.4 87.3 70.1 87.2 4 22.1 39.6 27.8 10.5

Aggregate 5541 80.6 88.7 66.8 67.6 6 15.2 38.0 34.8 12.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among FSWs who
sold sex in the last week.

5.4.3 Reason for Not Using Condom in the Last Sex with Client

In the survey, FSWs were asked for the reason they did not use condom in their last sex with a
client (Table 5.15). Overall the most common reason cited was client’s request (32.9%), and this
was the number one reason in Pekalongan City (93.0%). The second most common reason overall
was condom inavailability (27.5%).

Condom inavailability was never the reason for not using condom in Batam City, South Jakarta
City and Pekalongan City. In Sumenep District, almost half of FSWs (45.9%) said they did not use
condom as they had already taken some medicine to prevent pregnancy, while condom should be
used not simply to prevent pregnancy, but to prevent transmission of STI and HIV/AIDS.

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 Table 5.15 FSW’s Reason for Not Using Condom during Last Sex with Client
Reason for Not Using Condom during Last Sex with Client (%)

Had taken Had taken

District/Municipality n* Condom
medicine to medicine to Respondents No obligation Clients felt Client paid Client’s
not Other
prevent prevent felt clean to use condom clean more Request
available
infection pregnancy

Simeulue# 70 25.7 0.0 0.0 0.0 1.4 0.0 0.0 0.0 0.0

Bukittinggi City# 6 16.7 0.0 0.0 0.0 33.3 0.0 0.0 16.7 16.7

Ogan Komering Ulu (OKU) 237 35.4 6.3 10.1 10.1 5.9 13.5 2.1 16.9 4.6

Pangkal Pinang City 167 19.2 11.4 10.8 3.6 7.2 8.4 7.2 31.1 1.2

Batam City 32 0.0 18.8 3.1 15.6 3.1 46.9 21.9 9.4 3.1

South Jakarta City 16 0.0 0.0 0.0 18.8 12.5 0.0 0.0 6.3 25.0

West Jakarta City 64 21.9 7.8 6.3 10.9 3.1 7.8 1.6 9.4 31.3

North Jakarta City 103 12.6 6.8 3.9 18.4 2.9 12.6 10.7 27.2 11.7

Sukabumi City 169 44.4 4.7 12.4 23.7 0.0 12.4 18.9 40.2 0.0

Bekasi City 98 48.0 5.1 5.1 8.2 10.2 8.2 8.2 49.0 3.1

Depok City 91 37.4 0.0 9.9 33.0 5.5 16.5 2.2 28.6 2.2

Pekalongan City 129 0.0 0.0 0.0 0.0 0.0 0.0 14.7 93.0 0.0

Sumenep 268 24.3 30.2 45.9 17.5 12.3 21.6 31.0 31.3 0.0

Surabaya City 146 35.6 7.5 6.2 27.4 11.0 26.0 16.4 20.5 2.1

Gianyar 80 41.3 1.3 0.0 7.5 8.8 3.8 0.0 1.3 18.8

Balikpapan City 128 42.2 1.6 1.6 14.8 13.3 28.1 8.6 45.3 7.0

Maluku Tenggara Barat# 45 22.2 0.0 6.7 24.4 2.2 8.9 0.0 8.9 17.8

Jayapura City 111 1.8 2.7 2.7 7.2 0.0 9.9 2.7 36.0 5.4

Aggregate 1839 27.5 8.9 12.1 14.2 6.6 14.6 11.9 32.9 4.8

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *The number of
FSWs who did not use condom in their last sex with client.

5.4.4 Age at First Vaginal Sex

The median age of first vaginal sex overall was 18 years (Table 5.16). The youngest at 17 years
old was found in Bekasi City, and the oldest at 20 years old was found in Sumenep District, which
was actually a very young age to already be exposed to sex. Overall, almost half or the majority of
FSWs (49.8%) had their first vaginal sex between the age of 18 to 24 years. The second most
common age range was 15-17 years (29.9%).

The 18-24-year age range was the most common age for first vaginal sex in all the
Districts/Municipalities that were surveyed. The highest proportion was in Surabaya City
(61.6%) while for first vaginal sex in the 15-17-year age range, the highest proportion was found
in Sukabumi City (45.4%). There was also 3.0% of FSWs who had their first vaginal sex at ≤14
years (Table 5.16), the highest proportion was among FSWs in North Jakarta City (7.4%) and
Gianyar District (7.3%). This was a very young age that made those young girls highly vulnerable
to risky sexual behavior. In other survey sites the proportion of FSWs who started sex before they

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 turned 14 was less than 1%, i.e. in Ogan Komering Ulu (0.6%), South Jakarta City (0.8%), Depok
City and Pekalongan City (0.3%). Further analysis revealed that the majority of FSWs who started
vaginal sex at a very young age (≤14 years) did not go to school (7.7%) or only completed
elementary school/equivalent (8.5%).

Table 5.16 Age of First Vaginal and Anal Sex among FSWs
Age at
Age at
First Age at First Vaginal Sex in Years Age at First Anal Sex in Years
First
Vaginal (%) (%)
District/Municipality n* n** Anal Sex
Sex
Do not Do not
Median ≤ 14 15 - 17 18 - 24 ≥ 25 remember Median ≤ 14 15 - 17 18 - 24 ≥ 25 remember

Simeulue# 73 18 0 20.5 35.6 4.1 39.7 72 18.5 0.0 16.7 37.5 4.2 41.7

Bukittinggi City# 22 18 0 31.8 54.5 4.5 9.1 2 31 0.0 0.0 0.0 50.0 50.0

Ogan Komering Ulu (OKU) 340 19 0.6 16.2 40.6 5.6 37.1 157 18 0.0 17.8 22.9 1.9 57.3

Pangkal Pinang City 361 18 2.5 26.6 34.6 3.3 33.0 106 18 0.0 14.2 26.4 1.9 57.5

Batam City 382 18 3.4 27.5 55.2 3.4 10.5 118 19 0.0 18.6 34.7 5.9 40.7

South Jakarta City 397 18 0.8 35.0 59.2 4.0 1.0 15 19 13.3 13.3 40.0 6.7 26.7

West Jakarta City 398 18 5.0 30.9 57.3 1.3 5.5 29 18 3.4 17.2 41.4 6.9 31.0

North Jakarta City 394 18 7.4 41.4 44.9 2.3 4.1 60 14 33.3 18.3 10.0 0.0 38.3

Sukabumi City 399 17 1.8 45.4 20.3 0.3 32.3 162 18 0.0 11.1 13.0 0.0 75.9

Bekasi City 394 19 2.8 24.6 53.0 4.1 15.5 60 18.5 0.0 5.0 11.7 0.0 83.3

Depok City 399 18 0.3 27.6 47.1 3.8 21.3 80 18 0.0 12.5 23.8 1.3 62.5

Pekalongan City 397 19 0.3 21.9 72.5 4.3 1.0 21 20 0.0 0.0 9.5 4.8 85.7

Sumenep 356 20 3.1 17.7 58.1 7.9 13.2 139 20 0.0 15.1 40.3 9.4 35.3

Surabaya City 398 19 1.8 30.7 61.6 2.8 3.3 31 21 0.0 0.0 16.1 3.2 80.6

Gianyar 233 18 7.3 28.3 36.5 3.9 24.0 87 20 0.0 12.6 27.6 6.9 52.9

Balikpapan City 200 18 4.5 35.0 49.5 3.0 8.0 48 18 0.0 12.5 14.6 2.1 70.8

Maluku Tenggara 56 19 3.6 32.1 58.9 1.8 3.6 23 19 0.0 17.4 52.2 4.3 26.1
Barat#
Jayapura City 371 18 6.5 38.5 49.6 1.9 3.5 126 18 0.0 34.9 42.9 7.9 14.3

Aggregate 5419 18 3.0 29.9 49.8 3.4 13.9 1239 18 1.9 15.8 26.2 3.9 52.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *FSWs who have
had vaginal sex with missing data taken out; **FSWs who have had anal sex with missing data taken out.

5.4.5 Age at First Anal Sex

Overall, the median age FSWs first had anal sex was 18 years (Table 5.16). The youngest at 14
years old was found in North Jakarta City, and the oldest, at 20 years old was found in Sumenep
and Gianyar Districts. More than half of FSWs (52.3%) did not remember at what age they first
had anal sex. A quarter of them (26.2%) started between the age of 18 to 24 years, and 15.8%
started as teenagers between 15 to 17 years of age.

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 The majority of FSWs who started anal sex in the 18-24-year age range was found in Jayapura
City (42.9%). The second biggest proportion, FSWs who started anal sex between 15 to 17 years
old was also found in Jayapura City (34.9%). Those who started before age 14 was not found in
the majority of Districts/Municipalities. The highest was found in North Jakarta City (33.3%).
Similar to the age pattern of first vaginal sex, the majority of FSWs had their first anal sex between
the age of 18 to 24. The second most common age range was 15-17 years for both vaginal and
anal sex. The proportion of FSWs who started vaginal sex before the age of 14 was higher (3.0%)
than those who started anal sex at that age (1.9%). The highest proportion of FSWs who started
vaginal and anal sex at a very young age (≤14 years) was found in North Jakarta City.

5.4.6 Age at First Time Selling Sex

Selling sex is engaging in sexual activity and receives payment in the form of money or goods
(Table 5.17). The median age FSWs started selling sex was 23 years. The youngest was 21 years
in North Jakarta City, Sukabumi City and Pekalongan City, younger than the aggregate median
age. The median age of first vaginal sex and first selling sex only differed by one year in Bekasi
City and by two years in Pekalongan City (at 19 years vs 21 years).

The oldest median age was 27 years in Depok City. This was 9 years after FSWs in this city on
average started vaginal sex. Overall, the majority of FSWs started selling sex between the age of
18 to 24 (47.2%), which was also the age range most FSWs started having vaginal and anal sex.

In eight Districts/Municipalities, more than half of FSWs started selling sex when they were 18-
24 years. The highest proportion was in Sukabumi City (58.2%) and the lowest was in Depok City
(32.7%) (Table 5.17). The second most common age group was ≥25 years (40.1%), and in three
Districts/Municipalities more than half FSWs started selling sex at this age. These were Depok
City (60.8%), Gianyar District (56.9%) and Surabaya City (53.8%). In contrast, only 20% of FSWs
in Sukabumi City started selling sex older than 25 years. A smaller proportion of FSWs (9.6%)
sold sex for the first time when they were 15 to 17 years old, the majority was found in North
Jakarta City (17.3%). There was also a smaller proportion of FSWs (2.35%) who started selling
sex before the age of 14, and the highest proportion was found in Sumenep District (8.3%). This
put them at high risk of STI and HIV/AIDS infection.

Table 5.17 Age FSWs Started Selling Sex and Expect to Stop Selling Sex

Age of First Age FSWs

Age of First Time Selling Sex in Age FSWs Expect to Stop
Time Selling Expect to Stop
District/Municipality n* Sex Years (%) n** Selling Sex Selling Sex in Years (%)

Median ≤ 14 15 - 17 18 - 24 ≥ 25 Median ≤ 25 26 - 34 35 - 44 ≥ 45
Simeulue# 73 20 5.5 23.3 56.2 15.1 15 23 60.0 13.3 13.3 13.3

Bukittinggi City# 22 19 4.5 22.7 54.5 18.2 22 29 45.5 18.2 27.3 9.1

Ogan Komering Ulu (OKU) 368 23 1.6 6.8 50.5 41.0 253 35 17.8 26.9 29.6 25.7

123
 Age of First Age FSWs
Age of First Time Selling Sex in Age FSWs Expect to Stop
Time Selling Expect to Stop
District/Municipality n* Sex Years (%) n** Selling Sex Selling Sex in Years (%)

Median ≤ 14 15 - 17 18 - 24 ≥ 25 Median ≤ 25 26 - 34 35 - 44 ≥ 45
Pangkal Pinang City 379 24 1.6 5.5 44.6 48.3 323 32 20.1 33.4 35.0 11.5

Batam City 384 24 0.8 3.4 50.5 45.3 360 30 23.1 49.4 24.4 3.1

South Jakarta City 395 22 1.3 13.2 52.9 32.7 365 30 26.8 38.9 30.4 3.8

West Jakarta City 397 22 2.5 14.9 46.1 36.5 378 29 36.0 36.8 17.2 10.1

North Jakarta City 394 21 4.1 17.3 47.7 31.0 350 27.5 43.4 31.7 18.0 6.9

Sukabumi City 292 21 6.8 14.4 58.2 20.5 309 40 2.3 18.4 52.8 26.5

Bekasi City 396 22 1.3 11.6 52.8 34.3 357 35 15.1 26.9 47.1 10.9

Depok City 398 27 1.3 5.3 32.7 60.8 235 35 16.6 24.3 33.2 26.0

Pekalongan City 390 21 0.3 14.9 55.6 29.2 394 32 7.9 45.4 30.5 16.2

Sumenep 385 23 8.3 8.8 43.1 39.7 344 45 1.5 10.8 29.1 58.7

Surabaya City 400 25 0.5 5.0 40.8 53.8 331 35 12.1 31.4 34.7 21.8

Gianyar 232 26 1.7 6.9 34.5 56.9 193 36 16.1 24.4 45.1 14.5

Balikpapan City 197 23 1.0 4.6 54.8 39.6 192 30 18.2 43.2 25.5 13.0

Maluku Tenggara 58 23 0.0 12.1 41.4 46.6 56 30 23.2 46.4 21.4 8.9
Barat#
Jayapura City 368 24 1.9 8.2 44.3 45.7 343 31 20.4 39.1 27.1 13.4

Aggregate 5375 23 2.3 9.6 47.2 40.1 4727 33 18.9 32.6 31.5 17.1

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *FSWs who had
sold sex with missing data taken out; **FSWs who would like to stop selling sex with missing data taken out.

5.4.7 Age FSWs Expect to Stop Selling Sex

In the survey, FSWs were first asked if they desired to stop selling sex and the majority (85.8%)
said yes. A follow-on question was then about the age FSWs expected to stop, and the median age
was 33 years (Table 5.17). The oldest median age was 45 years in Sumenep District, and the
youngest was 27.5 years in North Jakarta. In general, the majority said they would like to stop
selling sex in the age range of 26 to 44 years, but there was a great variation between District. For
example, almost half of FSWs (43.3%) in North Jakarta would like to stop sex work before they
turned 25, but there was also 6.9% who wanted to stop when they reach ≥45 years. In Sumenep
District, more than half of FSWs (58.7%) would like to stop when they were older (≥45 years).

5.4.8 Length of Time in Sex Work

The length of time an FSW had worked selling sex was calculated from her current age subtracted
with the age she first sold sex. Overall FSWs had been working for 5 years, while on average in
each District/Municipality the length varied between 3 to 9 years (Table 5.18). The shortest time
was 3 years in Batam City and Gianyar District, and the longest was 8 years in Sukabumi and
Sumenep Districts.

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 Table 5.18 Length of Time in Sex Work

Length of Selling Sex in Years (%)

Average Length of
District/Municipality n*
Selling Sex (in Years) ≤1 2-4 5-9 ≥ 10

Simeulue# 73 9 8.2 15.1 32.9 43.8

Bukittinggi City# 22 7 9.1 40.9 27.3 22.7

Ogan Komering Ulu (OKU) 368 4 17.4 62.8 12.0 7.9

Pangkal Pinang City 379 4 37.7 41.4 14.0 6.9

Batam City 384 3 41.9 42.2 12.5 3.4

South Jakarta City 395 4 31.1 45.3 17.5 6.1

West Jakarta City 397 5 17.6 48.1 23.2 11.1

North Jakarta City 394 4 40.1 35.3 15.0 9.6

Sukabumi City 292 8 3.4 46.9 23.3 26.4

Bekasi City 396 5 10.4 48.5 36.9 4.3

Depok City 398 4 14.8 56.3 24.9 4.0

Pekalongan City 390 5 14.6 46.9 27.9 10.5

Sumenep 385 8 4.7 37.7 25.2 32.5

Surabaya City 400 5 29.0 38.5 18.8 13.8

Gianyar 232 3 48.3 37.1 9.9 4.7

Balikpapan City 197 4 25.9 41.1 23.4 9.6

Maluku Tenggara Barat# 58 4 43.1 31.0 12.1 13.8

Jayapura City 368 5 25.8 32.9 25.5 15.8

Aggregate 5375 5 23.8 44.3 20.9 11.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Missing data had
been taken out

Most FSWs had been selling sex for 2-4 years (44.3%) followed with ≤1 year (22.8%) (Table 5.18).
In Gianyar District, almost half of FSWs (48.3%) had just started sex work less than a year ago,
while in contrast, one in three FSWs in Sumenep District (32.5%) had been selling sex for ≥10
years. The majority (37.1%) of length in sex work in almost all Districts/Municipalities was 2-4
years except in Gianyar District. The highest proportion of the 2-to 4-year time length was found
in Ogan Komering Ulu (OKU) (62.8%). In Bekasi City on the other hand, 36.9% of FSWs had been
in the sex industry for 5-9 years. The length of time working as sex workers is important as the
longer an individual works selling sex, the higher chance she will be infected with HIV/AIDS or
STI from the multiple partners that she had.

5.5 Other Risk Behavior

The survey also asked FSWs about other risk behaviors that they engaged in such as alcohol
consumption and use of drugs in the last three months, use of injectable drugs, injecting drug
practices (needle sharing), and use of drugs and injectable drugs by sex partners.

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 5.5.1 Alcohol Consumption and Substance Abuse

Alcohol consumption and use of illicit drugs are considered as risk factors for risky sexual
behavior. Alcohol influences someone’s cognitive capacity and impacts the body’s immune
system, but a more direct correlation between alcohol and disease transmission was mainly
because an individual who is under the influence of alcohol tends to assume a riskier lifestyle,
such as having unprotected sex (Amelia, et al., 2016).

Overall, 53.3% of FSWs consumed alcohol in the last three months. The majority was found in
Balikpapan City (89.6%) and the lowest proportion was found in Sumenep District (24.3%). Drug
was used by 5.1% of FSWs and 0.5% of FSWs also injected drugs in the last three months. Among
those who injected drugs, 40.0% also shared needles in their last injection. With regards to sex
partners, 4.0% used drugs before sex, and from those 4.0%, 9.0% used drugs by injection (Table
5.19).
Analysis revealed that 67% of FSWs who consumed alcohol in the last three months commonly
carried out sexual transaction in bars/cafes. That indicated that alcohol consumption was linked
with sex transaction venues. A previous study also reported that alcohol consumption was more
dominant among younger FSWs (Bowen KJ, et al., 2011), and the result of this survey supported
that. As much as 65.3% FSWs between the age of 15 to 19 consumed alcohol in the last three
months.

Table 5.19 Alcohol and Drug Consumption among FSWs

Alcohol
Drug Use in the Needle Sharing Drug Injection
Consumption in Injecting Drug Drug Use by Sex
District/Municipality n Last Three
Use (%)
during the Last
Partner (%)
by Sex Partner
the Last Three
Months (%) Injection (%)* (%)**
Months (%)
Simeulue# 72 4.2 4.2 1.4 100.0 4.2 0.0

Bukittinggi City# 22 45.5 27.3 0.0 0.0 13.6 0.0

Ogan Komering Ulu (OKU) 370 37.3 4.9 1.1 0.0 4.6 11.8

Pangkal Pinang City 384 54.4 2.9 0.0 0.0 2.6 0.0

Batam City 385 83.9 18.4 2.1 75.0 6.2 0.0

South Jakarta City 397 62.2 1.0 0.0 0.0 1.0 0.0

West Jakarta City 400 44.5 6.8 1.8 25.0 3.5 7.1

North Jakarta City 400 73.0 3.3 0.5 14.3 6.8 11.1

Sukabumi City 400 64.5 3.0 1.3 50.0 3.3 23.1

Bekasi City 399 40.6 10.0 1.3 60.0 7.0 17.9

Depok City 401 31.9 1.7 0.2 80.0 3.7 0.0

Pekalongan City 397 42.1 0.3 0.0 0.0 1.8 0.0

Sumenep 400 24.3 5.5 0.3 0.0 1.8 14.3

Surabaya City 400 39.3 7.3 0.0 0.0 8.0 0.0

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 Alcohol
Drug Use in the Needle Sharing Drug Injection
Consumption in Injecting Drug Drug Use by Sex
District/Municipality n Last Three
Use (%)
during the Last
Partner (%)
by Sex Partner
the Last Three
Months (%) Injection (%)* (%)**
Months (%)
Gianyar 235 53.6 2.6 1.3 0.0 3.4 25.0

Balikpapan City 202 89.6 3.0 0.0 66.7 5.0 10.0

Maluku Tenggara Barat# 59 61.0 1.7 1.7 0.0 5.1 33.3

Jayapura City 371 78.7 3.5 1.1 0.0 1.6 33.3

Aggregate 5541 53.3 5.1 0.7 40.0 4.0 9.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among FSWs who
inject drugs; **Among FSW’s sex partner who use drugs.

Unmarried FSWs consumed alcohol more than married FSWs (58.1%) and drug was used more
by those who consumed alcohol in the last three months than by those who did not. This finding
was in line with previous studies that reported a higher level of alcohol consumption among
unmarried FSWs and also FSW’s tendency to use drug in addition to drinking alcohol (Sharma SK,
et al., 2016; Chen, 2013).

Alcohol consumption however correlates negatively with quality of life. Alcohol can interfere with
an individual’s intelligence, impair their cognitive function, making them more emotional. Alcohol
intoxication also disrupts neurophysiological and psychomotor performance of an individual
(Feodorian, BP, 2014). This finding indicated that FSWs who consumed alcohol and drugs should
be a priority target of HIV and STI prevention programs (Founck et al., 2011; Samet JH et al., 2010;
Heravian A et al., 2010).

5.5.2 Coerced Sex

Table 5.20 presents information on coerced sex that FSWs experience, either during their first
sex, and during any sex in the last year. As much as 10.2% FSWs experienced their first sex under
duress, the majority was in West Jakarta City (21.8%) and the lowest proportion was in
Pekalongan City (0.5%).

The survey also asked about who forced FSWs into having sex in the last year, and the majority
said it was their clients (8.6%). The highest proportion was in Surabaya City (21.3%) and the
lowest was in Depok City (1.7%). FSW’s steady partner however made up the second most
common perpetrator (7.5%), followed by non-steady partner (3.3%). The highest proportion of
coercion from the steady partner was found in South Jakarta (24.9%), and the lowest was in
Pekalongan City (0.0%). A small proportion (0.2%) of FSWs also faced sexual coercion from a
family member in the last year.

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 Table 5.20 Coerced Sex among FSWs in the Indonesian 2018-2019 IBBS

Perpetrator of Coercion (%)*

Coerced
District/Municipality n Sex Steady Partner Non-Steady
Client / Family
(%) (non-paying Partner (non- Stranger Other
Customer Member
partner) paying partner)
Simeulue# 73 4.1 0.0 2.7 0.0 0.0 0.0 6.8

Bukittinggi City# 22 4.5 9.1 4.5 4.5 0.0 0.0 0.0

Ogan Komering Ulu (OKU) 370 6.2 1.9 2.4 0.3 2.2 0.0 1.9

Pangkal Pinang City 384 12.8 6.5 1.6 1.0 0.5 0.0 0.0

Batam City 385 12.5 10.1 2.3 1.0 1.0 0.0 0.0

South Jakarta City 397 5.3 3.5 24.9 6.8 0.0 0.0 0.0

West Jakarta City 400 21.8 13.5 7.0 4.0 1.5 0.0 0.8

North Jakarta City 400 15.3 12.0 7.8 5.3 3.3 1.3 1.3

Sukabumi City 400 6.3 3.0 22.0 0.3 0.0 0.3 0.0

Bekasi City 399 11.0 9.5 2.0 3.0 1.5 0.5 0.0

Depok City 401 10.0 1.7 5.7 8.5 0.7 0.2 0.5

Pekalongan City 397 0.5 12.8 0.0 0.0 0.0 0.0 0.0

Sumenep 400 8.5 8.0 14.8 12.5 1.3 0.3 0.3

Surabaya City 400 4.5 21.3 0.5 1.3 0.5 0.0 0.0

Gianyar 235 6.4 0.9 9.8 0.9 0.4 0.0 1.3

Balikpapan City 202 13.9 19.3 8.4 1.5 0.5 0.0 1.0

Maluku Tenggara Barat# 59 22.0 0.0 3.4 0.0 1.7 0.0 22.0

Jayapura City 371 19.1 6.2 4.0 0.8 0.5 0.0 1.1

Aggregate 5541 10.2 8.6 7.5 3.3 1.0 0.2 0.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Findings indicate that FSWs faced aggression more from their steady partners than from non-
steady partners. A similar situation was reported among FSWs in India (Karandikar S, Próspero
M, 2010). Law Number 23/2004 of Indonesia on the Elimination of Domestic Violence states that
sexual violence is every action that forces someone to have sexual intercourse, to have sex in an
unnatural or undesirable way, or to have sex with another person for commercial and/or other
purposes.

5.6 Access to Condom

Condom is a contraception device that works by preventing sperm from entering the vagina.
Condom use is one method to prevent transmission of HIV/AIDS and STI. One factor that plays a
role in HIV or STI transmission is a high number of clients. The more clients a FSW has, the higher
probability she will be infected with HIV or STI, particularly if she has been engaging in
unprotected sex. On the other hand, a small number of clients may influence a FSW’s bargaining

128
 power to use condom as she would be worried she may lose a client if she insisted on using
condom (Jazan S, et al., 2003).

5.6.1 Access to Condom

Access to condom is an important matter, as it would impact FSW’s opportunity to use condom.
The Indonesian Minister of Health Decree Number 21/2013 on HIV and AIDS Intervention in
correlation with drug and medical supplies provision states that the central and local government
guarantees the availability of medicine and medical supplies that are needed for HIV and AIDS
intervention program.

Based on this decree condom was considered as medical or health supplies. The IBBS found that
almost half of FSWs (45.4%) bought condom (Table 5.21), one in four FSWs did not have condom
(25.7%), 17.8% of FSWs received free condoms and 11.1% FSWs bought as well as obtained free
condoms. In this survey, FSWs who were asked about their source of condom were FSWs who
knew about condom (Table 5.21).

In Pekalongan City none of the FSWs (0.0%) received free condoms. Most of them bought condom
on their own (98.5%). This situation was seen in eight Districts/Municipalities where more than
50% of FSWs there bought condom. In almost all Districts/Municipalities, less than 30% of FSWs
got free condoms, except in North Jakarta City where the percentage was higher (38.9%). In
contrast, in almost half of the Districts/Municipalities, FSWs who did not have condom was more
than 30%, i.e. in Simeulue District (80%), Bukititinggi City (33.3%), Ogan Komering Ulu (OKU)
District (68.2%), Sukabumi City (38.7%), Sumenep District (47.2%), Gianyar District (47.4%),
Balikpapan City (37.5%) and Maluku Tenggara Barat District (70.7%).

Table 5.21 Access to Condom and Brand of Condom used by FSWs

Ways to Obtain Condom in the Last Month (%) Brand of Frequently Used Condom (%)

District/Municipality n* Did not have Bought Got free Bought and got
Sutra Fiesta Durex Other
condom condom condom free condom

Simeulue# 15 80.0 20 0.0 0.0 26.7 0.0 6.7 66.7

Bukittinggi City# 21 33.3 52.4 9.5 4.8 28.6 52.4 19.0 0.0

Ogan Komering Ulu (OKU) 264 68.2 27.3 2.7 1.9 53.4 6.1 6.8 33.7

Pangkal Pinang City 346 22.0 34.1 27.7 16.2 84.7 3.8 5.2 6.4

Batam City 378 10.3 56.9 17.2 15.6 85.4 2.6 5.3 6.6

South Jakarta City 387 11.9 51.7 17.8 18.6 46.3 25.8 14.7 13.2

West Jakarta City 383 18.0 55.1 19.8 7.0 53.8 10.7 21.9 13.6

North Jakarta City 396 24.5 24.7 38.9 11.9 82.6 2.5 3.8 11.1

Sukabumi City 385 38.7 11.9 47.0 2.3 69.6 16.9 12.2 1.3

Bekasi City 368 26.9 50.0 7.1 16.0 41.0 30.7 26.9 1.4

129
 Ways to Obtain Condom in the Last Month (%) Brand of Frequently Used Condom (%)

District/Municipality n* Did not have Bought Got free Bought and got
Sutra Fiesta Durex Other
condom condom condom free condom

Depok City 379 16.1 39.8 25.1 19.0 64.9 19.0 2.9 13.2

Pekalongan City 397 1.3 98.5 0.0 0.3 79.1 17.4 3.5 0.0

Sumenep 390 47.2 41.3 7.7 3.8 52.6 30.0 17.2 0.3

Surabaya City 396 26.0 51.5 11.9 10.6 52.8 13.1 15.7 18.4

Gianyar 213 47.4 42.3 3.3 7.0 76.5 2.8 1.9 18.8

Balikpapan City 200 37.5 55.5 2.5 4.5 53.5 12.0 24.5 10.0

Maluku Tenggara Barat# 58 70.7 17.2 12.1 0.0 60.3 1.7 1.7 36.2

Jayapura City 338 19.5 39.1 13.9 27.5 73.7 11.2 9.3 5.8

Aggregate 5247 25.7 45.4 17.8 11.1 64.8 14.3 11.3 9.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *FSWs who know
about condom.

5.6.2 Source of Free Condom and Experience with Damaged or Torn Condom
This section presents the source of free condom as informed by FSWs who received free condom
in the last month (Table 5.22). The most common source was their pimp (33.7%), followed by
friends (20.5%), health facility (14.3%), NGO staff (11.9%). The least common source was
condom outlet (1.6%). The percentage however varied between sites. In several
Districts/Municipalities, Simeulue District, Bukittinggi City, Ogan Komering Ulu (OKU) District,
Pekalongan City, Sumenep District, Balikpapan City and Maluku Tenggara Barat District, no FSWs
received free condom from their pimps, while the highest proportion was among FSWs in North
Jakarta City (75.1%).

Table 5.22 Source of Free Condom and Experience with Torn Condom among FSWs

Source of Free Condom in the Last Month (%) Damaged/

District/Municipality n* Health Condom Outreach n** Torn Condom
Friends Client Pimp NGO Other (%)
Facility Outlet Worker

Simeulue# 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 15 0.0

Bukittinggi City# 3 0.0 33.3 0.0 0.0 66.7 0.0 0.0 0.0 21 0.0

Ogan Komering Ulu (OKU) 12 0.0 0.0 83.3 0.0 0.0 0.0 0.0 16.7 264 1.5

Pangkal Pinang City 152 18.4 5.9 0.7 56.6 8.6 9.9 0.0 0.0 346 4.3

Batam City 124 2.4 0.0 3.2 43.5 0.8 16.9 33.1 0.0 378 30.7

South Jakarta City 141 1.4 2.8 12.8 61.7 0.0 5.7 2.1 13.5 387 15.8

West Jakarta City 103 2.9 1.9 5.8 40.8 0.0 24.3 13.6 10.7 383 21.1

North Jakarta City 201 10.9 0.5 1.0 75.1 0.5 8.5 1.5 2.0 396 9.3

Sukabumi City 190 1.1 76.3 6.8 5.3 2.6 2.1 5.3 0.5 385 7.0

Bekasi City 85 4.7 48.2 2.4 18.8 3.5 14.1 8.2 0.0 368 11.7

Depok City 167 4.8 31.7 27.5 2.4 0.0 29.9 1.2 2.4 379 10.8

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 Source of Free Condom in the Last Month (%) Damaged/
District/Municipality n* Health Condom Outreach n** Torn Condom
Friends Client Pimp NGO Other (%)
Facility Outlet Worker
Pekalongan City 1 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 397 17.9

Sumenep 45 0.0 86.7 13.3 0.0 0.0 0.0 0.0 0.0 390 18.2

Surabaya City 89 15.7 9.0 0.0 25.8 0.0 13.5 36.0 0.0 396 21.2

Gianyar 22 77.3 0.0 0.0 4.5 0.0 13.6 4.5 0.0 213 18.3

Balikpapan City 14 14.3 7.1 0.0 0.0 7.1 14.3 57.1 0.0 200 9.5

Maluku Tenggara Barat# 7 28.6 14.3 28.6 0.0 0.0 0.0 0.0 28.6 58 3.4

Jayapura City 167 66.5 3.6 0.0 21.6 0.0 6.6 0.6 1.2 365 22.5

Aggregate 1513 14.3 20.5 7.1 33.7 1.6 11.9 8.1 2.8 5247 15.1
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of FSWs
who received free condom, or bought and received free condom; **Number of FSWs who knew about condom

Damaged or torn condom occurred in practically every District/Municipality except in Simeulue

District and Bukittinggi City (0.0%). Overall, 15.1% of condom were damaged or torn. The largest
number of cases was in Batam City (30.7%) followed by Jayapura City and West Jakarta City
(22.5% and 21.1% respectively). This increased FSWs’ risk for HIV/AIDS or STI transmission.

Currently, 15,000 condom outlets have been established, and each year 20 million condoms are
distributed, either as free commodities or as commercial products. The National AIDS
Commission (NAC) had initiated a comprehensive HIV prevention program using structural
interventions, including establishing condom outlets, in 12 Districts/Municipalities. Up to year
2014, the number of condom outlets was planned to be increased to 36 with funding support from
GF R8 (NAC, 2010). The 2018-2019 IBBS however found that only 1.6% FSWs received condom
from a condom outlet. This finding can be a basis for further optimization of condom outlets.

5.7 Sexually-Transmitted Infection (STI)

Sexually-transmitted Infection (STI) is an infection caused by various microbes/bacteria, virus,
parasite and genital lice that mostly spreads through sexual contact. Not all STIs cause symptoms
and any symptom that appears does not always appear on the genital (MOH, 2017). More than 30
types of pathogens can be transmitted through sexual contact and the clinical manifestation
varies according to sex/gender and age. While sexually-transmitted infection (STI) is primarily
transmitted through sex, transmission may also occur from a pregnant woman to her baby in the
uterus or during childbirth, through contaminated blood or tissue. Sometimes transmission also
occurs through medical devices (MOH, 2016). In the 2018-2019 IBBS, FSWs were asked about
any STI symptoms that they experienced in the last year, any testing and treatment that they
received and the location of testing and treatment.

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 5.7.1 STI Symptom, Testing and Treatment

Five types of STI symptoms were asked to FSWs, i.e. vaginal discharge that has a foul odor,
sore/ulcer in the genital area, bumps around the genital, pain during urination, and warts in the
vaginal area (Table 5.23). The most common symptom stated by FSWs was vaginal discharge with
a foul odor (24.8%) followed by pain during urination (7.5%) while the least common symptom
was wart in the vaginal area (1.0%). The highest proportion of foul-smelling vaginal discharge
was reported by FSWs in Batam City (52.5%), while genital ulcer was reported mostly from
Jayapura City (12.7%). Pain during urination was primarily reported by FSWs in Bekasi City
(18.5%), while vaginal wart was the most common symptom of FSWs in Pangkal Pinang City
(3.1%).

The five STI symptoms were then recoded into a variable of ‘ever experienced STI symptom’. A
FSW would be categorized as having STI symptoms if she experienced at least one of the five
symptoms. If she did not experience any of the five symptoms, then she would be considered as
never experiencing STI symptoms. The result was that a third (29.3%) of FSWs had experienced
at least one STI symptom. More than half of FSWs in Batam City (56.1%) had experienced at least
one symptom (Table 5.23). The lowest proportion of FSWs with STI symptoms was found in
Pekalongan City (8.8%).

Table 5.23 STI Symptom, Testing and Treatment among FSWs

STI Symptom in the Last Year (%)

Experienced Visited a Recommend
Foul- STI Test
District/ Sore/ulcer Bumps Pain Wart at least one Health STI Test to
n smelling STI symptom
≤6 months n** n***
Municipality around the around the during around ago (%)
Provider Partner
Vaginal (%)* (%) (%)
genital genital urination the vagina
Discharge
Simeulue# 72 66.7 6.9 4.2 30.6 5.6 76.4 0.0 0 0.0 0 0.0

Bukittinggi City# 22 13.6 4.5 0.0 0.0 4.5 13.6 0.0 3 33.3 1 100.0

Ogan Komering 15.4 1.9 1.4 6.2 0.8 17.6 1.1 6 100.0 6 50.0
370
Ulu (OKU)
Pangkal Pinang 384 15.1 4.2 2.1 4.4 3.1 17.2 7.6 47 21.3 10 90.0
City
Batam City 385 52.5 7.5 3.1 17.9 0.8 56.1 34.0 157 62.4 98 25.5

South Jakarta City 397 15.4 1.3 0.5 1.5 0.5 15.9 25.2 110 43.6 48 8.3

West Jakarta City 400 30.8 3.5 1.5 4.3 0.5 34.8 24.3 120 27.5 33 33.3

North Jakarta City 400 23.0 9.8 2.5 9.5 2.3 32.8 28.0 126 28.6 36 22.2

Sukabumi City 400 28.0 3.8 0.8 8.5 0.8 31.8 15.0 65 24.6 16 25.0

Bekasi City 399 41.6 5.0 3.3 18.5 2.0 50.9 3.0 33 69.7 23 17.4

Depok City 401 20.4 0.5 0.5 10.2 0.0 27.2 2.7 18 55.6 10 40.0

Pekalongan City 397 8.6 0.3 0.0 1.0 0.0 8.8 0.0 1 0.0 0 0.0

Sumenep 400 27.8 8.8 2.8 3.5 0.3 28.3 7.0 54 40.7 22 7.5

Surabaya City 400 13.0 1.8 1.3 7.3 0.8 19.0 27.5 146 27.4 40 42.1

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 STI Symptom in the Last Year (%)
Experienced Visited a Recommend
Foul- STI Test
District/ Sore/ulcer Bumps Pain Wart at least one Health STI Test to
n smelling STI symptom
≤6 months n** n***
Municipality around the around the during around ago (%)
Provider Partner
Vaginal (%)* (%) (%)
genital genital urination the vagina
Discharge

Gianyar 235 28.1 6.8 3.0 8.1 2.6 33.6 7.2 49 38.8 19 16.7

Balikpapan City 202 17.3 3.0 5.9 6.9 1.0 26.2 5.4 20 60.0 12 100.0

Maluku Tenggara 59 44.1 3.4 1.7 5.1 1.7 50.8 5.1 7 14.3 1 28.3
Barat#
Jayapura City 371 32.6 12.7 1.1 4.3 0.5 39.9 73.6 291 68.0 198 0.0

Aggregate 5541 24.8 4.7 1.8 7.5 1.0 29.3 18.0 1243 45.9 571 24.7
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *a composite
variable from several questions about STI symptom (having 1 or more of the 5 STI symptoms); **Number of FSWs who ever had STI
test; ***Number of FSWs who ever visited a health provider.

Among all the FSWs, only 18.0% ever had been tested for STI in the last six months, which was
only 60% of the FSWs who experienced STI symptoms. This might be because the survey asked
for STI symptoms that were experienced in the last year, and some FSWs may have been tested 7
to 12 months ago. The highest proportion of FSWs who went for STI testing in the last six months
was found in Jayapura City (73.6%). This percentage was actually twice the percentage of STI
symptom that FSWs in Jayapura City experienced, which indicated good awareness about STI. On
the other hand, only 3.0% of FSWs in Bekasi City were tested for STI in the last six months, while
the proportion with symptoms was actually 50.9%.

FSWs who had STI test were also asked about treatment they received, and those who visited a
health provider was actually less than half (45.9%). In Jayapura City, despite the high proportion
of STI test, only 60.8% received treatment from a health provider. In most
Districts/Municipalities, coverage of treatment by a health provider was below 50% (Table 5.23).
Those who did see a health provider, 54.12% of them had foul-smelling vaginal discharge.

Preventing and treating STI can reduce the risk for sexual transmission of HIV, particularly among
those with multiple sex partners like FSWs and their clients. Inflammation or ulcers as a result of
STI can increase the risk of infection from an infected person to the partner during unprotected
sex (MOH, 2016). Among FSWs who visited a health provider, only 24.7% suggested STI testing
to their partner, while in Jayapura City, none of them suggested their partner to be tested,
eventhough quite a high proportion of FSWs there obtained STI treatment from a health provider.
Yet, STI testing and treatment on the partner is necessary in order to stop the chain of
transmission.

5.7.2 Location of STI Testing and Treatment

Almost half of FSWs (44.3%) who went for STI testing went to a Puskesmas (Table 5.24). This
was because Puskesmas was a health facility that was closest to the community and was easily
accessed by FSWs. Other FSWs (18.3%) had an STI test at a mobile VCT service, and an additional
18.9% went to a Center for Reproductive Health (PKR). Both of these services are operationalized

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 by Puskesmas and are under the coordination of Puskesmas. This showed the important role of
Puskesmas as a primary care facility for STI testing among FSWs.

While 66.7% of FSWs obtained treatment at the Puskesmas, some chose a doctor’s private
practice (13.8%) or other facilities such as private clinic, private midwife, company clinic, etc.
(19.4%) (Table 5.24). The proportion of STI treatment in Puskesmas was higher than the
proportion of STI testing as FSWs who got tested at a mobile VCT may go to Puskesmas for
treatment. This was consistent with the finding that the most common location for STI testing and
treatment was Puskesmas. It indicated that Puskesmas was the most easily accessible health
facility that is utilized the most by FSWs.

Table 5.24 Location of STI Testing and Treatment

Location of Last STI Test (%) Location of STI Treatment (%)

District/ Municipality n* Private NGO Mobile n** Puskesmas/ Doctor’s
Puskesmas Hosp Other
Private Practice Other
Clinic Clinic VCT Hospital
Simeulue# 0 0.0 0.0 0.0 0.0 0.0 0.0 0 0.0 0.0 0.0

Bukittinggi City# 3 66.7 0.0 0.0 0.0 33.3 0.0 1 100.0 0.0 0.0

Ogan Komering Ulu 6 83.3 0.0 16.7 0.0 0.0 0.0 6 100.0 0.0 0.0
(OKU)
Pangkal Pinang City 47 63.8 0.0 8.5 0.0 14.9 12.8 10 90.0 0.0 10.0

Batam City 157 47.8 4.5 17.8 0.6 29.3 0.0 98 80.6 15.3 4.1

South Jakarta City 110 22.7 4.5 10.0 0.9 24.5 37.3 48 50.0 12.5 37.5

West Jakarta City 120 28.3 6.7 30.8 0.8 30.0 3.3 33 51.5 48.5 0.0

North Jakarta City 126 28.6 5.6 10.3 0.0 55.6 0.0 36 69.4 22.2 8.3

Sukabumi City 65 92.3 7.7 0.0 0.0 0.0 0.0 16 93.8 6.3 0.0

Bekasi City 33 63.6 3.0 18.2 3.0 12.1 0.0 23 78.3 0.0 21.7

Depok City 18 83.3 0.0 11.1 5.6 0.0 0.0 10 80.0 20.0 0.0

Pekalongan City 1 100.0 0.0 0.0 0.0 0.0 0.0 0 100.0 0.0 0.0

Sumenep 54 74.1 25.9 0.0 0.0 0.0 0.0 22 57.5 37.5 5.0

Surabaya City 146 46.6 3.4 26.7 0.0 23.3 0.0 40 57.9 10.5 31.6

Gianyar 49 49.0 6.1 18.4 12.2 4.1 10.2 19 66.7 33.3 0.0

Balikpapan City 20 45.0 25.0 30.0 0.0 0.0 0.0 12 0.0 0.0 100.0

Maluku Tenggara 7 14.3 28.6 0.0 14.3 28.6 14.3 1 58.6 5.1 36.4
Barat#
Jayapura City 291 37.1 0.0 0.7 0.0 0.7 61.5 198 0.0 0.0 0.0

Aggregate 1243 44.3 4.8 12.7 0.9 18.3 18.9 571 66.7 13.8 19.4
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; * Number of FSWs
who ever received STI test; **Number of FSWs who ever visited a health provider

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 5.8 Human Immunodeficiency Virus (HIV)
HIV (human immunodeficiency virus) is a virus that attacks the human immune system by
infecting and destroying the CD4 cells. As a result, the body can no longer protect itself from
various diseases (opportunistic infections). The more CD4 cells are destroyed, the weaker the
body becomes, and the more vulnerable the individual will be toward various diseases (MOH,
2017). In the 2018-2019 IBBS information that related to HIV was gathered, starting from HIV
testing to treatment.

5.8.1 HIV Test and Location of HIV Test

The IBBS collected information about HIV test, location of test, consent before testing, counseling,
receipt of HIV test result, reason for getting or not getting HIV test, reason for not disclosing the
HIV test result, and past or current HIV treatment.

Table 5.25 HIV Test and Location of Last HIV Test among FSWs

HIV Test Location of Last HIV Testing from FSWs who Had HIV Test
(%) (%)

District/Municipality n Yes, on own n*

Yes, on Yes,
Initiative and Private NGO Mobile
own based on Never Puskesmas Hospital Other
based on Clinic Clinic VCT
initiative referral
referral
Simeulue# 72 0.0 0.0 0.0 100.0 0 0.0 0.0 0.0 0.0 0.0 0.0

Bukittinggi City# 22 31.8 0.0 4.5 63.6 8 50.0 12.5 0.0 0.0 37.5 0.0

Ogan Komering Ulu (OKU) 370 1.4 0.3 1.4 97.0 11 36.4 27.3 0.0 0.0 27.3 9.1

Pangkal Pinang City 384 9.6 7.3 7.6 75.5 94 22.3 1.1 1.1 1.1 71.3 3.2

Batam City 385 30.9 4.7 32.7 31.7 263 31.2 3.8 4.9 4.2 54.8 1.1

South Jakarta City 397 30.2 8.3 16.6 44.8 219 26.5 5.5 3.7 1.4 35.2 27.9

West Jakarta City 400 34.8 20.5 10.0 34.8 261 23.4 3.4 13.4 17.2 39.1 3.4

North Jakarta City 400 36.0 8.3 18.8 37.0 252 16.7 3.6 1.2 4.8 73.8 0.0

Sukabumi City 400 2.8 4.8 12.3 80.3 79 82.3 8.9 0.0 2.5 6.3 0.0

Bekasi City 399 0.8 13.0 2.5 83.7 65 36.9 3.1 0.0 12.3 47.7 0.0

Depok City 401 3.7 6.7 13.0 76.6 94 43.6 9.6 0.0 6.4 40.4 0.0

Pekalongan City 397 10.3 0.8 0.0 88.9 44 9.1 0.0 0.0 0.0 90.9 0.0

Sumenep 400 8.5 3.0 2.5 86.0 56 91.1 8.9 0.0 0.0 0.0 0.0

Surabaya City 400 15.5 25.5 30.5 28.5 286 39.9 2.8 5.6 0.3 51.4 0.0

Gianyar 235 31.5 10.2 19.1 39.1 143 37.1 5.6 10.5 5.6 20.3 21.0

Balikpapan City 202 34.2 6.4 17.3 42.1 117 44.4 0.9 0.0 0.9 51.3 2.6

Maluku Tenggara Barat# 59 47.5 8.5 11.9 32.2 40 7.5 30.0 2.5 0.0 40.0 20.0

Jayapura City 371 59.8 4.6 28.3 7.3 344 32.8 0.9 1.2 0.0 0.3 64.8

Aggregate 5541 19.8 8.4 13.9 58.0 2328 33.7 3.7 4.1 4.2 39.9 14.3

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#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of FSWs
who ever had HIV test

As shown in Table 5.25, more than half of FSWs (58.0%) never had HIV test. Only 19.8% took the
initiative to get tested, showing that the level of awareness about HIV risk was still low. This may
also relate to the low level of HIV knowledge, which was around 61%, and level of comprehensive
knowledge about HIV was only 16%. Analysis revealed that the higher a FSW’s educational level
was, the more knowledge she had regarding HIV and the more likely she would be to get tested,
i.e. around 20.9%. In Jayapura City, the majority of FSWs have had HIV test (92.75%), while the
lowest coverage of HIV test was found in Ogan Komering Ulu (OKU) District (3.0%), which meant
that as much as 97% of FSWs in Ogan Komering Ulu (OKU) District have never had HIV test.

The most common location FSWs visited for their last HIV test was the mobile VCT (39.9%),
followed by Puskesmas (33.4%). Mobile VCT is an HIV testing service outside the Puskesmas
building that is organized by Puskesmas as a way to actively bring services closer to the
community. Few FSWs went to a hospital for HIV test (3.7%) (Table 5.25). The mobile VCT
program has been quite effective in providing FSWs with essential health services. Similar to STI,
in HIV testing, Puskesmas also plays a critical role in reaching out to FSWs who otherwise would
never access HIV and STI-related health care.

5.8.2 Reason for Getting and Not Getting HIV Test

The survey tried to find factors that can inhibit FSWs from getting HIV test, as well as factors that
can promote testing, FSWs were therefore asked about their reason for getting or not getting an
HIV test (Table 5.26). Most of FSWs who had HIV test did so because they felt they were at risk
(54.7%). Others got tested based on request/recommendation/referral by a health worker
(16.5%), or by a field outreach worker (14.7%). The majority of FSWs who got tested because
they felt at risk was in Pangkal Pinang City (84.8%) and the lowest proportion was in Pekalongan
City (7.1%).

Among FSWs who did not get HIV test, the most common reason was because they felt
healthy/not at risk (42.5%), followed by not knowing that they needed to be tested (26.5%) or
did not want to know their HIV status (18.2%). That last group may actually feel afraid or worried
that their test result may be positive. More than half of FSWs in Depok City (58.3%) did not get
tested because they felt healthy/not at risk. This showeds that the level of awareness about HIV
among FSWs was still low. Some FSWs also did not know where to go for HIV test (8.8%). These
individuals, along with those who did not know they needed HIV test were FSWs whose level of
knowledge about HIV was still low. This showed the importance of health promotion activities to
FSWs in order to improve their knowledge and awareness about HIV.

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 Table 5.26 Reason for Getting and Not Getting HIV Test among FSWs

Reasons for Getting HIV Test (%) Reasons for Not Getting HIV Test (%)
Requested/ Do not Do not
District/ Requested/ Feel Do not
n* recommended n** want to know
Municipality Feel recommended healthy/ know HIV
/ referred by a Other know where to Other
at-risk / referred by a Not at- test is
field outreach HIV go for
health worker risk needed
worker status testing
Simeulue# 0 75.0 0.0 0.0 0.0 72 94.4 0.0 4.2 0.0 1.4

Bukittinggi City# 8 18.2 0.0 0.0 25.0 14 85.7 7.1 0.0 0.0 7.1

Ogan Komering Ulu 11 44.7 36.4 0.0 45.5 359 49.6 24.2 6.7 16.7 2.8
(OKU)
Pangkal Pinang City 94 84.8 37.2 12.8 5.3 290 29.3 33.1 22.4 11.0 4.1

Batam City 263 66.2 4.6 9.5 1.1 122 23.0 27.9 34.4 10.7 4.1

South Jakarta City 219 66.7 11.0 11.9 11.0 178 30.9 36.0 11.2 13.5 8.4

West Jakarta City 261 59.9 16.5 9.2 7.7 139 71.9 15.8 1.4 5.8 5.0

North Jakarta City 252 72.2 17.9 14.7 7.5 148 37.8 24.3 8.8 15.5 13.5

Sukabumi City 79 9.2 12.7 12.7 2.5 321 71.0 16.8 9.0 1.2 1.9

Bekasi City 65 20.2 27.7 40.0 23.1 334 35.0 41.0 10.2 9.6 4.2

Depok City 94 50.0 8.5 61.7 9.6 307 20.2 58.3 13.7 6.8 1.0

Pekalongan City 44 7.1 11.4 2.3 36.4 353 23.5 1.7 71.7 1.7 1.4

Sumenep 56 28.3 60.7 5.4 26.8 344 77.3 5.2 12.8 1.5 3.2

Surabaya City 286 37.8 19.6 29.0 23.1 114 48.2 32.5 3.5 12.3 3.5

Gianyar 143 57.3 25.2 2.8 34.3 92 35.9 37.0 0.0 17.4 9.8

Balikpapan City 117 17.5 3.4 22.2 17.1 85 8.2 45.9 12.9 29.4 3.5

Maluku Tenggara 40 66.0 55.0 2.5 25.0 19 84.2 0.0 0.0 5.3 10.5
Barat#
Jayapura City 344 75.0 11.6 2.0 20.3 27 44.4 25.9 3.7 3.7 22.2

Aggregate 2328 54.7 16.1 14.7 14.5 3213 42.5 26.5 18.2 8.8 4.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of FSWs
who have had HIV test; **Number of FSWs who never had HIV test

5.8.3 Reason for Not Disclosing the HIV Test Result

The IBBS asked whether FSWs who had HIV test and received the test result disclosed the result
to anyone, and if not why. Half of FSWs (51.1%) did not disclose their test result to anyone out of
fear of discrimination, while a third (31.9%) were afraid of losing their job. Lack of societal
acceptance toward HIV-positive individuals have made some PLHIV hide their status from even
people who are closest to them (Butt L, et al., 2010).

Stigma against PLHIV has had a significant impact on HIV/AIDS prevention and intervention
program, as well as on PLHIV’s quality of life. At-risk population become less willing to get tested
as they are afraid they would be ostracized if the result turns out to be positive. HIV-positive
people are also reluctant to reveal their status and may even postpone treatment of any illness,
which will further damage their health and spread HIV uncontrollably. Insufficient knowledge

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 and experience, or negative attitude toward HIV are seen as factors that promote stigma and
discrimination (Syaluhiyah Z, et al., 2015).

Table 5.27 Reason for Not Disclosing HIV Test Result among FSWs

Reason for Not Disclosing HIV Test Result (%)

District/Municipality n* Fear of Fear of Losing Fear of Losing Fear of Being

Other
Discrimination a Job a Partner Shunned by Family

Simeulue# 0 0.0 0.0 0.0 0.0 0.0

Bukittinggi City# 0 0.0 0.0 0.0 0.0 0.0

Ogan Komering Ulu (OKU) 3 33.3 0.0 0.0 0.0 33.3

Pangkal Pinang City 23 34.8 30.4 4.3 8.7 8.7

Batam City 75 20.0 74.7 8.0 14.7 1.3

South Jakarta City 68 14.7 39.7 7.4 4.4 39.7

West Jakarta City 44 70.5 52.3 13.6 18.2 18.2

North Jakarta City 38 42.1 23.7 2.6 26.3 31.6

Sukabumi City 6 16.7 0.0 0.0 16.7 83.3

Bekasi City 21 81.0 85.7 61.9 90.5 4.8

Depok City 47 14.9 8.5 2.1 29.8 12.8

Pekalongan City 1 100.0 100.0 100.0 100.0 0.0

Sumenep 47 89.4 4.3 34.0 78.7 0.0

Surabaya City 55 58.2 47.3 14.5 7.3 3.6

Gianyar 13 38.5 30.8 30.8 30.8 69.2

Balikpapan City 51 58.8 5.9 3.9 3.9 5.9

Maluku Tenggara Barat# 7 14.3 0.0 42.9 28.6 28.6

Jayapura City 134 77.6 14.9 2.2 3.7 4.5

Aggregate 626 51.1 31.9 10.7 19.3 13.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of FSWs
who had HIV test and received the result but did not reveal the result to anyone

Knowledge about HIV/AIDS has a large influence on how people treat HIV-positive individuals.
Stigma against PLHIV arises because people do not know how HIV is transmitted, and react
negatively in response to the HIV/AIDS epidemic (Herek GM, Capitanio JP, Widaman KF, 2002). If
people have adequate knowledge about risk factors, transmission, prevention and treatment of
HIV/AIDS, then stigma against PLHIV will decrease. Reduced stigma and increased social support
from the community will make PLHIV feel less isolated, and more accepted such that they will be
more inclined to utilize health care (Shaluhiyah, Musthofa, & Widjanarko, 2015). Stigmatized
PLHIV may be more likely to not seek help, delay or even end treatment (Ardani I. & Handayani
S., 2017). Similarly, stigma against FSWs influences HIV test uptake, and HIV-positive FSWs are
more likely to be discriminated than FSWs who are HIV negative (Elizabeth J. King, et al., 2013).

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 Stigmatizing attitude may take various forms, from derogatory words and actions, to rough
treatment and ignorance about one’s opinion (Ardani I. & Handayani S., 2017). The Regulation of
the Minister of Health Republic of Indonesia Number 74/2014 on HIV Counseling and Testing
Guideline states that one objective of HIV counseling and testing is to eliminate stigma and
discrimination (MOH RI, 2014).

5.8.4 HIV Test

The guideline for HIV counseling and testing is a mandatory reference for health providers,
program managers, HIV professional counselors, workplace managers and other relevant
stakeholders that provide HIV counseling and testing. Counseling and testing are necessary in
order to diagnose HIV, prevent transmission or increased numer of HIV cases and initiate
treatment as early as possible (MOH RI, 2014). This survey gathered information about HIV
testing that FSWs had in the last 12 months, about consent before testing, counseling, receipt of
test result, receipt of test result in ≤ 2 hours, and offer of HIV test to the FSW’s partner.

Data analysis revealed that 95.7% of FSWs who have had HIV test did the test in the last 12
months. In fact, in Surabaya City and Sumenep District the proportion was 100% (Table 5.28). As
the only “entrance” to prevention, treatment, care and support services, HIV testing has to
continually be increased, in quantity and quality. One way to increase testing coverage would be
to offer HIV test to STI patients, TB, Hepatitis B or C patients, and PLHIV’s partner, and to repeat
HIV test every 6 months for members of key population (PWID, FSWs, MSM and their sex
partners, also Waria) (MOH RI, 2014). The survey found that only 5% of FSWs ever offered HIV
test to their partner.

Several factors played a role in FSW’s partner’s decision to get HIV test. Some men consider HIV
test shameful as they link the test with their masculinity (Paul J. Fleminga, et al., 2017). The low
coverage of HIV test among FSW’s clients showed that intervention and preventive efforts are
needed for this group (Paul J. Fleminga, et al., 2017).

Table 5.28 Testing, Consent, Counseling and Receipt of Test Result among FSWs

Consent was Received HIV Received Suggested

Received
HIV Test in the Obtained Before Counseling Before Test Result HIV Test to
District/Municipality n* Test Result n***
Last 12 Months Blood Draw for HIV Receiving Test in ≤ 2 hours Steady Sex
(%)
Test Result (%) (%)** Partner (%)
Simeulue# 0 0.0 0.0 0.0 0.0 0.0 14 0.0

Bukittinggi City# 8 75.0 100.0 87.5 100.0 62.5 9 33.3

Ogan Komering Ulu (OKU) 11 81.8 81.8 54.5 63.6 14.3 113 1.8

Pangkal Pinang City 94 96.8 98.9 77.7 61.7 82.8 97 7.2

Batam City 263 97.3 98.5 94.3 92.4 64.6 60 15.0

South Jakarta City 219 98.2 98.2 81.3 92.2 71.3 166 12.0

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 Consent was Received HIV Received Suggested
Received
HIV Test in the Obtained Before Counseling Before Test Result HIV Test to
District/Municipality n* Test Result n***
Last 12 Months Blood Draw for HIV Receiving Test in ≤ 2 hours Steady Sex
(%)
Test Result (%) (%)** Partner (%)
West Jakarta City 261 97.7 97.3 92.7 94.3 54.9 192 11.5

North Jakarta City 252 96.8 98.8 98.4 95.2 76.3 116 13.8

Sukabumi City 79 94.9 100.0 98.7 97.5 97.4 145 7.6

Bekasi City 65 92.3 98.5 92.3 83.1 85.2 72 1.4

Depok City 94 95.7 98.9 98.9 97.9 95.7 107 3.7

Pekalongan City 44 97.7 100.0 100.0 97.7 0.0 143 0.0

Sumenep 56 100.0 100.0 96.4 89.3 8.0 198 0.5

Surabaya City 286 100.0 97.6 92.7 93.0 69.5 191 13.6

Gianyar 143 95.1 97.2 86.0 75.5 70.4 153 12.4

Balikpapan City 117 99.1 100.0 95.7 96.6 92.0 103 6.8

Maluku Tenggara Barat# 40 95.0 95.0 87.5 90.0 11.1 37 24.3

Jayapura City 344 98.8 99.7 99.1 99.1 92.1 175 15.4

Aggregate 2328 95.7 98.5 93.0 91.9 72.9 2031 8.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of FSWs
who ever had HIV test; **among FSWs who received HIV test result; ***Number of FSWs who had a steady partner

Among FSWs who had HIV test, the majority (98.5%) stated that informed consent was obtained
from them before testing. Post-test counseling was also given to 93.0% of FSWs, indicating that
there were still 7% of missed opportunities for counseling. Yet, consent and counseling are part
of 5 globally-agreed basic HIV service (MOH RI, 2014). HIV counseling and testing was initiated
in Indonesia in 2004, through counseling and testing on the initiative of clients or known as
voluntary counseling and testing (VCT) (MOH RI, 2014). Up to now, VCT is still performed for
clients who would like to know their HIV status. Since 2010, a provider-initiated testing and
counseling (PITC) approach was implemented. These two approaches, VCT and PITC, have the
goal to provide universal access, eliminate stigma and discrimination, and reduce missed
opportunities in preventing HIV infection and transmission (MOH RI, 2014).

HIV Testing and Counseling service (HTC) is the main gate to prevention, care, support and
treatment services. In its national policy and strategy, the government has established the
concept of universal access to know one’s HIV status, to get access to HIV prevention, care,
support and treatment with a vision of “getting to zero”, i.e. zero new HIV infection, zero
discrimination dan zero AIDS-related deaths. In implementation, HIV testing has to follow the
globally-agreed principle that consists of 5 basic components known as 5Cs (informed Consent,
Confidentiality, Counseling, Correct test results, Connection to care, treatment and prevention
services) (MOH RI, 2014).

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 5.8.5 HIV Treatment

Adherence in ARV therapy will have a positive impact on the health of an individual and the
community, as the quality of PLHIV’s life improves and HIV transmission in the society decreases.
As more PLHIV receive treatment, the positive impact will be larger and we would move closer to
achieving the “3 zeroes”: zero new infection, zero stigma and discrimination, zero AIDS-related
deaths (MOH RI, 2013). During the IBBS interview, FSWs were asked about any HIV treatment
package they received and any subsequent actions. This section presents the information from
FSWs which included ever taking ARV, still taking ARV until now, ever stopped taking ARV for
more than three months, viral load test in the last 12 months and knowing the result of the viral
load test (Table 5.29).

ARV was provided to 92.4% of FSWs who enrolled in a CST service and 84.6% of those FSWs were
still continuing to take ARV, which meant that 15.4% of FSWs had stopped taking ARV. Among
those who were still retained in care, 4.6% did stop the treatment for more than three months
before returning to care. As listed in Table 5.29, 87.7% of FSWs who ever received ARV also
received viral load test, and 80% of the viral load test was performed in the last 12 months. As
much as 86.7% of FSWs received their viral load test result.

Together with other countries, Indonesia is committed to implement a 90-90-90 Fast-Track

approach that aims to detect 90% of those who are infected, provide early ARV therapy to 90%
of those who are identified as positive, and achieve viral load suppression in 90% of PLHIV who
are taking ARV. This Fast-Track approach is expected to reduce the number of new infections of
HIV in line with the sustainable development goals (SDGs) target (MOH RI, 2019).

Increased coverage of HIV testing has to be accompanied with increased access to follow-on
service, one of which is ARV therapy. Aside from fulfilling a treatment function, ARV therapy also
serves a preventive function as part of treatment as prevention strategy. Every ARV therapy
referral hospital at the Provincial and District/Municipality level has to be able to guarantee
access to ARV therapy for PLHIV, while primary health facility can perform early detection of HIV
and gradually initiate ARV therapy (MOH RI, 2014).

Table 5.29 HIV Treatment among FSWs

Is Taking ARV Stopped Taking ARV Viral Load Test Know the Viral
Receive Viral Load Test
District/Municipality n* until now for More Than 3 in the Last 12 Load Test Result
ARV (%) (%)1
(%)1 Months (%)2 Months3 (%)3

Simeulue# 0 0.0 0.0 0.0 0.0 0.0 0.0

Bukittinggi City# 0 0.0 0.0 0.0 0.0 0.0 0.0

Ogan Komering Ulu (OKU) 0 0.0 0.0 0.0 0.0 0.0 0.0

Pangkal Pinang City 0 0.0 0.0 0.0 0.0 0.0 0.0

Batam City 0 0.0 0.0 0.0 0.0 0.0 0.0

South Jakarta City 1 100.0 100.0 0.0 100.0 0.0 100.0

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 Is Taking ARV Stopped Taking ARV Viral Load Test Know the Viral
Receive Viral Load Test
District/Municipality n* until now for More Than 3 in the Last 12 Load Test Result
ARV (%) (%)1
(%)1 Months (%)2 Months3 (%)3

West Jakarta City 3 100.0 66.7 0.0 66.7 100.0 0.0

North Jakarta City 3 100.0 66.7 0.0 33.3 100.0 100.0

Sukabumi City 3 66.7 100.0 0.0 0.0 0.0 0.0

Bekasi City 0 0.0 0.0 0.0 0.0 0.0 0.0

Depok City 2 100.0 100.0 50.0 100.0 50.0 100.0

Pekalongan City 0 0.0 0.0 0.0 0.0 0.0 0.0

Sumenep 5 80.0 50.0 50.0 25.0 0.0 100.0

Surabaya City 0 0.0 0.0 0.0 0.0 0.0 0.0

Gianyar 1 100.0 100.0 0.0 100.0 100.0 100.0

Balikpapan City 0 0.0 0.0 0.0 0.0 0.0 0.0

Maluku Tenggara Barat# 0 0.0 0.0 0.0 0.0 0.0 0.0

Jayapura City 10 100.0 100.0 0.0 70.0 100.0 100.0

Aggregate 28 92.9 84.6 4.6 87.7 80.0 86.7

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of FSWs
who received CST service; 1Among FSWs who received ARV therapy; 2Among FSWs who receive ARV until now; 3Among FSWs who
received viral load test

Currently, ARV therapy is the most effective prevention for HIV transmission. An HIV-positive
individual with an HIV-negative partner (serodiscordant couple) has to be informed that ARV
therapy also intends to reduce the risk of transmission to the HIV-negative partner (Ying Qing
Chena, et al., 2008). PLHIV with CD4 count <350 cells/mm3, or have active pulmonary TB, or have
Hepatitis B, or are currently pregnant or breastfeeding, or PLHIV who will be starting ARV
therapy need to receive information that emphasizes the aspect of prevention of transmission so
that adherence to ARV therapy can improve. A PLHIV with a serodiscordant partner and CD4
count >350 cells/mm3 without any other contraindications should be offered to immediately
initiate ARV therapy with the intention to reduce the risk of infecting his/her partner. This
prevention effort using antiretroviral is part of Treatment as Prevention (TasP) activity that in
Indonesia is called SUFA (Strategic Use of Antiretrovirals). It is critical to realize that reduced
number of viral particles as a result of ARV has to be accompanied with decreased risk behavior,
consistent and appropriate use of ARV, consistent condom use, safe sex and safe drug use
practices, consistent STI treatment at the appropriate regimen. They are imperative to prevent
HIV transmission. This effort is known as positive prevention (MOH RI, 2014).

5.9 Tuberculosis (TB)

Tuberculosis or abbreviated TB is a communicable disease caused by Mycobacterium tuberculosis,
that can invade the lungs and other organs. TB is one outcome that the 2018-2019 IBBS looked

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 at. TB-related information that is presented included TB symptoms that FSWs experienced in the
last year, TB testing, receipt of test result, TB treatment and HIV testing (Table 5.30).

Among all the FSWs interviewed, only 3.9% experienced coughs for more than two weeks in the
last year, and among FSWs who experienced TB symptoms, only 1.8% got tested. The majority
(91.2%) of those who were tested received their test result, but only 27.5% received TB
treatment. It is possible that the remaining 72.5% had a negative TB result, and therefore did not
need treatment.

During TB test, 450.5% of FSWs were offered HIV test, while among FSWs who had been or were
in TB treatment only 46.3% were offered HIV test. This showed that the coverage of HIV test
among TB patients was still very low and would need to be increased in line with the Regulation
of the Minister of Health Number 21/2013 on HIV Counseling and Testing. The regulation states
that through the provider-initiated testing and counseling (PITC) approach, every patient in TB
service has to be tested for HIV (MOH RI, 2013).

Low uptake of TB service among FSWs was influenced by the low level of knowledge and
awareness about TB. Previous studies had documented how educational level, income, age,
marital status and sex transaction venue affected TB knowledge of FSWs (Rana, Islam,
MoinUddin, Wadood, & Hossain, 2019). TB screening at health facilities is a cost-efficient strategy
for improving detection of TB (Chiang, Silifia S, et al., 2015).

Table 5.30 TB Symptom, Testing and Treatment among FSWs

Had coughs for Respondents who were Tested for TB (%)*
Had been
more than 2 weeks
District/Municipality n tested for TB Received the Received TB Offered HIV Test
in the last year
(%) TB Test Result Treatment Package during TB Service
(%)
Simeulue# 72 1.4 0.0 0.0 0.0 0.0

Bukittinggi City# 22 18.2 4.5 100.0 0.0 100.0

Ogan Komering Ulu (OKU) 370 5.1 3.0 81.8 72.7 0.0

Pangkal Pinang City 384 1.6 0.8 33.3 33.3 66.7

Batam City 385 4.2 0.5 100.0 50.0 50.0

South Jakarta City 397 2.3 1.3 100.0 20.0 40.0

West Jakarta City 400 2.0 1.5 66.7 0.0 16.7

North Jakarta City 400 5.8 2.3 100.0 0.0 66.7

Sukabumi City 400 0.8 0.3 100.0 0.0 100.0

Bekasi City 399 3.8 1.0 100.0 25.0 75.0

Depok City 401 4.7 2.2 88.9 77.8 55.6

Pekalongan City 397 0.0 0.0 0.0 0.0 0.0

Sumenep 400 1.8 1.5 100.0 83.3 83.3

Surabaya City 400 9.3 4.3 94.1 5.9 82.4

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 Had coughs for Respondents who were Tested for TB (%)*
Had been
more than 2 weeks
District/Municipality n tested for TB Received the Received TB Offered HIV Test
in the last year
(%) TB Test Result Treatment Package during TB Service
(%)
Gianyar 235 8.5 6.0 92.9 14.3 7.1

Balikpapan City 202 8.9 1.0 100.0 0.0 50.0

Maluku Tenggara Barat# 59 13.6 3.4 100.0 50.0 0.0

Jayapura City 371 4.9 3.5 100.0 7.7 38.5

Aggregate 5541 3.9 1.8 91.2 27.5 46.1

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among FSWs who
were tested for TB.

5.10 Hepatitis
Viral Hepatitis is an infectious inflammation of the liver that is caused by a virus. There are several
different types of hepatitis virus: A, B, C, D and E. The 2018-2019 IBBS looked at Hepatitis B and
C. This section presents information about Hepatitis B and C test, receipt of test result, and
Hepatitis B immunization that was obtained from interviews with FSWs (Table 5.31).

5.10.1 Hepatitis B

Viral Hepatitis B or known as Hepatitis B is an infectious inflammation of the liver that is caused
by the Hepatitis B virus (MOH RI, 2015). FSW’s knowledge about Hepatitis was still low (13.7%),
and the proportion of Hepatitis B test was still very low (3.5%). The majority of FSWs who were
tested received their test result (95.1%) and 71.1% received Hepatitis B immunization.

Table 5.31 Hepatitis B and C Testing and Treatment among FSWs

Hepatitis B (%) Hepatitis C (%)

District/Municipality n Hepatitis B Know the Hep B Hepatitis B Hepatitis C Know the Hep C
Test Test Result* Immunization* Test Test Result **
Simeulue# 72 0.0 0.0 0.0 0.0 0.0

Bukittinggi City# 22 0.0 0.0 0.0 0.0 0.0

Ogan Komering Ulu (OKU) 370 2.2 87.5 25.0 0.0 0.0

Pangkal Pinang City 384 0.3 100.0 100.0 0.0 0.0

Batam City 385 0.8 66.7 66.7 0.0 0.0

South Jakarta City 397 1.0 100.0 50.0 9.1 100.0

West Jakarta City 400 1.8 100.0 85.7 0.5 100.0

North Jakarta City 400 4.0 87.5 75.0 2.3 100.0

Sukabumi City 400 0.5 50.0 0.0 0.0 0.0

Bekasi City 399 2.3 100.0 11.1 1.8 85.7

Depok City 401 1.5 66.7 50.0 0.2 100.0

Pekalongan City 397 0.0 0.0 0.0 0.0 0.0

Sumenep 400 21.5 97.7 97.7 0.3 100.0

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 Hepatitis B (%) Hepatitis C (%)
District/Municipality n Hepatitis B Know the Hep B Hepatitis B Hepatitis C Know the Hep C
Test Test Result* Immunization* Test Test Result **
Surabaya City 400 5.8 100.0 30.4 0.5 100.0

Gianyar 235 0.9 100.0 100.0 0.4 100.0

Balikpapan City 202 2.0 100.0 75.0 2.0 100.0

Maluku Tenggara Barat# 59 0.0 0.0 0.0 0.0 0.0

Jayapura City 371 4.3 100.0 50.0 1.9 100.0

Aggregate 5541 3.5 95.1 71.1 1.3 98.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among FSWs who
had Hepatitis B test; **Among FSWs who had Hepatitis C test

5.10.2 Hepatitis C

The coverage of Hepatitis C test was lower than that of Hepatitis B (1.3%). The majority of FSWs
who were tested received their test result and one FSW had a positive test and received Hepatitis
C treatment. In Pekalongan City, none of the FSWs received Hepatitis B or C test, while in Pangkal
Pinang City and Sukabumi City none of the FSWs had Hepatitis C test (0.0%).

This low coverage of Hepatitis B or C test among FSWs showed that the level of knowledge and
awareness about the two illnesses was still low. Regulation of the Minister of Health Republic of
Indonesia Number 53/2015 on Viral Hepatitis Intervention states that Hepatitis B immunization
is needed for high-risk population groups, such as those who engaged in risky sexual practices
(MOH RI, 2015). Failure to negotiate condom use with clients will increase the risk of STI. Clients
who had unsafe sex are vulnerable toward various infectious diseases including Hepatitis B
(Matos et al., 2017). Female Sex Workers (FSWs) who use drugs are also at risk of getting
Hepatitis B (Matos et al., 2017).

5. 11 Other Prevention Program

Other prevention programs are activities that health provider or field worker do to reach out to
FSWs and provide them with promotive and preventive interventions. In this case, prevention
activities are related to HIV prevention among FSWs.

5.11.1 Exposure to HIV Prevention Program

Exposure to prevention program that was meant in the IBBS survey was meetings between FSWs
and field outreach workers, receipt of printed or audio-visual materials that relate to HIV, contact
with a health provider in the last three months, receipt of text messages containing information
about HIV prevention and transmission in the last month, and HIV-related information search
through a hotline service. Overall, 12.9% of FSWs had meetings or discussion with a field worker

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 in the last year (Table 5.31). The highest proportion was among FSWs in Batam City (29.9%) and
the lowest was in Ogan Komering Ulu (OKU) District (1.4%).

An equal number of FSWs (12.8%) also received printed materials (booklet, brochure, calendar,
leaflet) or audio-visual materials on the topic of HIV prevention and transmission. Only a tenth of
FSWs received free condom in the last month (10.3%) or were contacted by an outreach worker
in the last three months (9.4%). A small proportion of FSWs also received HIV-related text
messages (0.9%) or contacted a hotline service to find information on HIV (0.4%). Exposure of
FSWs to HIV prevention program was still very low, the majority of exposure was still below 10%.
Increased effort to reach FSWs with HIV prevention interventions, improve their knowledge and
awareness about HIV would be necessary. Coverage of HIV prevention program was the lowest
in Ogan Komering Ulu (OKU) District (1%).

Table 5.32 FSW’s Exposure to HIV Prevention Program

Contacted by Received Test Contacted a

Meet/Discuss Receive
Receive Free Field Outreach Message about Hotline Service to get
District/ with Field Printed/Audio
n Condom Worker in the HIV Prevention Information on HIV in
Municipality Outreach Worker Visual Material
(%) Last 3 Months in the Last Month the Last Month
(%) (%)
(%) (%) (%)
Simeulue# 72 1.4 1.4 0.0 1.4 0.0 0.0

Bukittinggi City# 22 9.1 18.2 4.5 0.0 4.5 0.0

Ogan Komering Ulu 370 1.4 1.4 0.5 0.0 0.3 0.3
(OKU)
Pangkal Pinang City 384 7.8 9.4 15.9 3.4 0.3 0.0

Batam City 385 29.6 23.1 27.0 31.2 1.0 0.5

South Jakarta City 397 13.6 12.3 8.8 22.7 4.8 0.8

West Jakarta City 400 8.8 15.3 13.5 17.5 0.5 0.0

North Jakarta City 400 13.0 12.8 10.3 9.3 1.0 1.0

Sukabumi City 400 20.0 19.8 11.5 6.5 0.0 0.0

Bekasi City 399 3.3 6.0 2.8 1.0 0.8 0.3

Depok City 401 12.5 11.0 14.2 13.0 0.5 0.7

Pekalongan City 397 13.6 13.1 2.3 0.0 0.0 0.5

Sumenep 400 11.3 7.3 2.3 3.3 0.0 0.3

Surabaya City 400 11.5 20.5 16.0 9.5 2.0 0.3

Gianyar 235 13.2 8.1 6.0 5.1 1.3 0.4

Balikpapan City 202 7.9 5.4 6.4 5.4 0.5 0.0

Maluku Tenggara 59 45.8 20.3 3.4 0.0 3.4 3.4

Barat#
Jayapura City 371 24.5 21.3 13.5 9.7 0.5 0.3

Aggregate 5541 12.9 12.8 10.3 9.4 0.9 0.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

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 5.11.2 Type of Information Received from Field Outreach Worker

Information dissemination to FSWs is an important health promotion activity to improve FSW’s

knowledge and awareness about HIV and STI as a group who is at high risk of getting HIV and STI.
Types of information that field outreach workers provided are listed in Table 5.33. This variable
was a multiple-answer question for which FSWs could give more than one answer.

The most common information FSWs received from field workers was about HIV test (31.1%),
followed by information about HIV transmission (23.3%), condom (20.1%) and STI (17.1%).
Despite being the most common type of information, actual HIV test among FSWs was still low
(42%). Coverage of STI test was also low, and even below the proportion of HIV testing.

Table 5.33 Information FSWs Receive from Field Outreach Workers

Type of Information Provided by Field Outreach Workers (%)

District/ Municipality n Drug/ Safe Basic CST for

HIV Peer
Injection / HIV Test Condom Health STI PLHIV TB PMTCT
Transmission Support
Overdose Care (ART)
Simeulue# 73 1.4 1.4 0.0 0.0 0.0 0.0 1.4 0.0 0.0 0.0

Bukittinggi City# 22 13.6 18.2 40.9 18.2 0.0 13.6 13.6 4.5 4.5 4.5

Ogan Komering Ulu 370 0.5 2.4 2.7 1.1 0.0 1.9 3.8 0.0 0.8 0.0
(OKU)
Pangkal Pinang City 384 3.9 18.2 19.0 19.0 1.3 3.9 8.6 0.8 0.5 0.3

Batam City 385 3.6 48.1 62.6 28.8 3.9 6.2 15.1 0.3 0.0 0.0

South Jakarta City 397 10.1 23.4 28.2 25.9 9.1 18.4 24.7 10.1 9.3 8.6

West Jakarta City 400 8.0 43.5 59.8 49.3 7.8 16.5 40.0 2.0 9.0 1.3

North Jakarta City 400 2.3 31.8 46.3 27.3 0.5 6.8 26.8 2.3 2.0 2.0

Sukabumi City 400 2.8 34.3 49.5 31.0 3.0 10.5 41.8 1.0 1.0 0.3

Bekasi City 399 2.5 11.0 13.5 4.8 1.3 4.8 8.3 1.3 1.8 1.0

Depok City 401 0.0 15.5 22.7 22.4 2.5 2.7 4.2 1.2 1.7 0.7

Pekalongan City 397 0.3 14.1 11.1 1.8 0.0 0.0 2.8 0.0 0.0 0.0

Sumenep 400 1.0 26.5 24.0 12.3 0.5 10.3 30.0 2.8 4.0 0.8

Surabaya City 400 0.0 28.5 42.3 18.8 0.3 2.5 15.5 2.0 0.3 0.5

Gianyar 235 6.8 23.4 26.4 11.9 4.3 4.3 11.1 4.3 3.4 2.6

Balikpapan City 202 0.5 17.3 37.6 19.3 0.0 1.0 3.5 0.0 0.0 0.0

Maluku Tenggara Barat# 59 10.2 32.2 30.5 6.8 1.7 15.3 5.1 1.7 1.7 0.0

Jayapura City 371 3.2 9.4 28.3 22.4 0.5 5.1 8.9 1.3 0.3 1.3

Aggregate 5541 3.0 23.5 31.7 20.1 2.4 6.6 17.1 2.0 2.3 1.3
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; PMTCT =
Prevention of Mother to Child Transmission

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 5.11.3 Barriers to HIV Service Access

Low uptake of HIV service by FSWs resulted in low coverage of HIV treatment. The survey
explored the barriers that FSWs faced in accessing HIV service and identified nine different
barriers, i.e. HIV service was not considered a need yet, lack of fund to access care, distance to
testing facility, the desire to be accompanied by another person to a health facility, fear of arrests,
fear of being caught by family member/friends, which indirectly related to fear of stigma and
discrimination, also service delivery process that was considered complicated, and inavailability
of HIV service (Table 5.34). This variable was also a multiple-answer question for which FSWs
could give more than one answer.

Table 5.34 Barriers to HIV Service Access among FSW

Barriers to HIV Service Access (%)

District/ Service Fear of being Service
n No Fear of
Municipality not Far No one to caught by procedure Service is
money No time being
needed Distance accompany friend/family/ is unavailable
yet arrested
yet feel embarrassed complicated
Simeulue# 73 1.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Bukittinggi City# 22 27.3 0.0 0.0 9.1 4.5 0.0 0.0 0.0 0.0

Ogan Komering Ulu 370 50.3 1.9 2.2 8.6 3.2 1.9 20.3 1.4 5.1
(OKU)
Pangkal Pinang City 384 27.9 5.7 10.7 19.0 12.2 2.9 6.3 0.3 1.0

Batam City 385 9.4 1.0 4.2 10.4 2.3 0.3 20.5 0.0 0.5

South Jakarta City 397 28.7 0.5 0.0 9.1 0.0 0.0 0.5 0.0 0.0

West Jakarta City 400 14.3 5.5 12.5 16.0 1.0 0.5 10.5 0.5 3.8

North Jakarta City 400 29.5 0.5 1.5 16.3 9.0 0.0 1.5 0.3 0.3

Sukabumi City 400 45.0 1.0 1.3 29.3 28.3 3.5 11.3 0.5 0.0

Bekasi City 399 3.8 1.3 5.0 8.0 1.3 0.5 22.6 1.0 1.0

Depok City 401 58.4 1.2 2.0 6.5 2.5 1.5 2.0 0.7 0.7

Pekalongan City 397 21.7 0.0 1.0 0.0 0.8 0.0 1.8 0.0 0.0

Sumenep 400 42.0 9.8 3.3 19.0 16.8 16.8 30.8 11.5 0.3

Surabaya City 400 11.0 1.8 5.3 6.8 2.5 5.8 11.8 4.8 0.0

Gianyar 235 35.7 3.4 4.7 8.9 4.7 0.9 1.7 0.4 2.6

Balikpapan City 202 38.6 3.0 6.9 28.2 9.9 1.0 3.0 1.0 0.5

Maluku Tenggara 59 40.7 5.1 1.7 3.4 3.4 0.0 6.8 0.0 1.7
Barat#
Jayapura City 371 5.4 0.5 1.6 0.8 0.5 0.3 0.3 0.5 0.0

Aggregate 5541 27.6 2.4 4.0 12.1 6.3 2.5 10.1 1.6 1.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Data analysis revealed that the biggest barrier to accessing HIV service was FSW’s perception that
they do not yet need the service (27.6%). This demonstrated a low level of knowledge and

148
awareness about HIV. Health promotion activities among FSWs therefore need to be intensified.
The Health Belief Model states that one factor that prompts an individual to practice preventive
behavior is the individual’s perception about the severity of a potential disease (Notoatmodjo,
2007). If an individual does not consider the disease to be a serious one, then he/she may tend to
not practice any prevention intervention.

The next biggest barrier was the lack of time to visit a health facility (12.1%). FSWs also
mentioned about fear of being caught by friends/family which was the third barrier (10.0%). As
reported by a study in Tanzania, support from partner and family is an important factor in a
woman’s decision to get or not get HIV test (De Paoli, et al., 2014).

5.12 Positivity Rate

The positivity rate was the result of biological testing among FSWs, which included test of HIV,
Syphilis, Hepatitis B and C; Chlamydia and Gonorrhea (CT/NG). The total specimens collected
from 18 Districts/Municipalities were 5760 for HIV test, 5772 for Syphilis test, 1192 for Hepatitis
B and C test. For Chlamydia and Gonorrhea (CT/NG) test, 1528 specimens were collected from
six Districts/Municipalities. Results are presented as an aggregate result from only 15
Districts/Municipalities where large enough samples were able to be collected for HIV and
syphilis test. Some Districts/Municipalities with small number of samples were not included in
the aggregate analysis. They were Simeulue District (80 samples for HIV and Syphilis test),
Bukittinggi City (0 samples for HIV and 20 samples for Syphilis test) and Maluku Tenggara Barat
District (60 samples for HIV and Syphilis test).

Hepatitis B and C test was performed in only three cities in West Java Province: Sukabumi City,
Bekasi City and Depok City. Chlamydia and Gonorrhea test was performed in six
Districts/Municipalities: Simueulue District, West Jakarta City, Bekasi City, Sumenep District,
Gianyar District and Balikpapan City but Simeulue District was not included in the aggregate data
analysis of Chlamydia and Gonorrhea due to its small number of samples (63 samples).

Result of the biological test was also presented per District/Municipality including the
District/Municipality with small number of samples.

5.12.1 Positivity Rate as an Aggregate

As an aggregate, there were 5610 HIV biological data and 5612 Syphilis data from FSWs.
Respondents were categorized as HIV positive when the anti-HIV test was reactive. A positive
syphilis result was divided into reactive, early-stage syphilis and late-stage syphilis to reflect the
stage of infection and the type of treatment needed. In the 2018-2019 IBBS, syphilis test result
was first divided into five categories: non-reactive, false positive syphilis, early-stage syphilis,
late-stage syphilis, and reactive. Then the result was streamlined into three categories: syphilis,

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 false positive syphilis, and non-reactive. A positive test result (early stage, late stage and reactive)
meant respondents had been infected with syphilis without further categorizing the stage of
infection. A category of non-reactive meant the test result was non-reactive while the category of
false positive meant the test result was inconsistent: reactive on the rapid test and non-reactive
on the titer test.

For Hepatitis B and C, the number of samples that were included in the aggregate analysis was
1192. These came from the three selected cities mentioned above. The total Chlamydia and
Gonorrhea samples collected from five Districts/Municipalities were 1465, but data from
Simeulue District was not included in the aggregate analysis due to its small number of samples.

35 31.1
95% CI (28,8 – 33,5)
30

25

20

15 11.4
95% CI (9,9 – 13,1) 8.6
10 95% CI (7,3 – 10,2)
2.1
5 95% CI ( 0,2 – 2,5) 1.4 1 0.2
95 % CI (1,1 – 1,7) 95% CI (0,6 – 1,8)
95% CI (0,1 – 0,7)
0
N= 5610 N=5612 N=1465 N=1465 N=1465 N=1192 N=1192
HIV* Syphilis Chlamydia** Gonorrhea** Chlamydia Hepatitis B Hepatitis C
* & Gonorrhea**
*Without Districts/Municipalities with small number of samples: Simeulue District, Bukittinggi City and Maluku Tenggara
Barat District; **Without Simeulue District that only had a small number of samples

Figure 5.1 Positivity Rate of HIV, STI, Hepatitis B and C, Chlamydia and Gonorrhea Aggregate Data in FSWs

Analysis on the FSW aggregate data (Figure 5.1) revealed an HIV positivity rate of 2.1% at 95%
CI (0.2 – 2.5). The positivity rate of syphilis was 1.4% at 95% CI (1.1 – 1.7). The positivity rate of
Chlamydia which was a sum of positive CT (Chlamydia) test and positive CT/NG (Chlamydia and
Gonorrhea) test was 31.1% at 95% CI (28.8 – 33.5). The positivity rate of Gonorrhea, which was a
sum of positive NG (Gonorrhea) and positive CT/NG (Chlamydia and Gonorrhea) test was 11.4%
at 95% CI (9.9 – 13.1). The positivity rate of both Chlamydia and Gonorrhea to reflect the mixed
infection of Chlamydia and Gonorrhea (positive CT/NG) was 8.6% at 95% CI (7.3 – 10.2). The
positivity rate of Hepatitis B as an aggregate was 1.0% at 95% CI (0.6 – 1.8) while the positivity
rate of Hepatitis C was lower: 0.2% at 95% CI (0.1 – 0.7). The analysis showed that FSWs had
quite a high positivity rate of Chlamydia and Gonorrhea, infectious diseases that are acute.

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 Interventions in the form of treatment would therefore be a priority case management for FSWs.
In terms of chronic diseases like HIV, Syphilis and Hepatitis, the positivity rate was quite low. This
requires treatment, as well as prevention interventions to decrease and prevent new cases.

5.12.2 Positivity Rate Per District/Municipality

Based on the positivity rate of each disease in each District/Municipality, five

Districts/Municipalities were identified as having HIV positivity rate higher than the aggregate
rate. The highest was Jayapura City (6.1%) while the remaining four sites were Gianyar District
(5.1%), Depok City (4.8%), Pangkal Pinang City (4.8%) and North Jakarta City (3.0%). The lowest
positivity rate of HIV was in Ogan Komering Ulu (OKU) District, i.e. 0.0% or no HIV positive was
diagnosed from FSWs there (Table 5.35). The positivity rate of Syphilis was highest in Batam City
(3.8%) and lowest in North Jakarta City (0.0%) (Table 5.35).

Table 5.35 Positivity Rate of HIV, STI, Hepatitis B and C, Chlamydia and Gonorrhea among FSWs per District/Municipality

Chlamydia
District/Municipality n HIV n Syphilis n Hep B Hep C n Chlamydia Gonorrhea and
Gonorrhea
Simeulue 80 0.0 80 0.0 63 1.6 0.0 0.0

Bukittinggi City 0 0.0 20 0.0

Ogan Komering Ulu (OKU) 395 0.0 395 0.8

Pangkal Pinang City 391 3.6 391 0.3

Batam City 400 1.5 400 3.8

South Jakarta City 399 1.3 399 0.8

West Jakarta City 400 0.8 400 2.8 355 52.1 20.3 18.0

North Jakarta City 400 3.0 400 0.0

Sukabumi City 392 0.3 394 2.0 392 0.3 0.0

Bekasi City 400 1.8 400 0.5 400 1.8 0.3 320 28.4 8.4 5.6

Depok City 400 4.8 400 0.5 400 1.0 0.3

Pekalongan City 395 0.5 395 0.3

Sumenep 400 1.3 400 2.0 399 5.3 0.8 0.8

Surabaya City 400 1.0 400 1.5

Gianyar 234 5.1 234 2.1 216 43.1 16.2 10.2

Balikpapan City 212 0.9 212 0.9 175 37.7 17.1 10.9

Maluku Tenggara Barat 60 3.3 60 3.3

Jayapura City 392 6.1 392 2.3

Note:
Hepatitis B and C test was not done in these sites

CT/NG test was not done in these sites

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The positivity rate of Hepatitis B varied between the three cities the survey looked at, starting
from 0.3% to 1.8%. The highest was in Bekasi City and the lowest was in Sukabumi City. Hepatitis
C was not found in Sukabumi City, so the positivity rate of Hepatitis C at 0.3% was calculated only
from two cities (Bekasi and Depok). For Chlamydia, the positivity rate also varied significantly
between sites, from as low as 5.3% in Sumenep District to 52.1% in West Jakarta, which was the
highest. West Jakarta also had the highest positivity rate for Gonorrhea (20.4%) and CT/NG mixed
infection (18.0%), and Sumenep District had the lowest positivity rate for both Gonorrhea and
CT/NG mixed infection (both at 0.8%).

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 Client
Client is another key population who was recruited to be respondents in the 2018-2019 IBBS.
Clients are men who have sex with female sex workers, occasionally or regularly. The 2018-2019
IBBS defined clients as men aged 15 or older who in the last three months had sex with female
sex workers.

This section presents and describes the analysis on the clients’ group that included the positivity
rate of HIV, Syphilis, Gonorrhea, Chlamydia, Chlamydia and Gonorrhea, Hepatitis B and C. Other
variables included client characteristics, knowledge about HIV/AIDS, its risk and prevention
method, sexual behavior and prevention, and programs that focus on HIV, TB, STI, Hepatitis B and
C. The minimum samples size required for the client group was 400 respondents from each
selected District/Municipality. The 2018-2019 IBBS selected 24 Districts/Municipalities from 16
provinces to be the survey sites for clients, so the total samples needed were 9600 clients. For the
biological component of the survey, samples for Hepatitis B and C test would be collected from
only four Districts/Municipalities in West Java Province. Up to the end of the survey, the number
of client samples had not met the targeted number. For the behavioral component, 8084
respondents were recruited, and for the biological component, a higher number of samples
managed to be collected (8197 samples). Coverage of behavioral data was 84.2%, while coverage
for the HIV biological data was 84.9% (8149 samples), and for syphilis biological data 81.2%
(7796 samples). The participation rate for both the behavioral and biological component of the
survey was below 90%, but for Hepatitis B and C biological data, the participation rate was 100%.
Planned and actual data collected from each District/Municipality is detailed in Table 6.1 below.

Table 6.1 Data Collection and Rate of Participation among Clients

Actual Behavioral Actual Biological Data- Actual Biological Data- Actual Biological Data -
District/ Data HIV Syphilis Hepatitis B and C
Plan
Municipality Participation Participation Participation Participation
n Rate (%)
n Rate (%)
n Rate (%)
n Rate (%)
West Sumatra

Bukittinggi City* 400 47 11.8 0 0.0 47 11.8

South Sumatra

Ogan Komering Ulu

400 336 84.0 381 95.3 381 95.3
(OKU)
Bangka Belitung

Pangkal Pinang City 400 400 100.0 400 100.0 400 100.0
Riau Islands
Batam City 400 400 100.0 400 100.0 400 100.0
DKI Jakarta
South Jakarta City 400 227 56.8 230 57.5 230 57.5
West Jakarta City 400 389 97.3 400 100.0 400 100.0
North Jakarta City 400 365 91.3 365 91.3 365 91.3

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 Actual Behavioral Actual Biological Data- Actual Biological Data- Actual Biological Data -
District/ Data HIV Syphilis Hepatitis B and C
Plan
Municipality Participation Participation Participation Participation
n Rate (%)
n Rate (%)
n Rate (%)
n Rate (%)
West Java

Bekasi 400 400 100.0 400 100.0 400 100.0 400 100,0
Sukabumi City 400 400 100.0 400 100.0 400 100.0 400 100,0
Bekasi City 400 400 100.0 400 100.0 400 100.0 400 100,0
Depok City 400 400 100.0 400 100.0 400 100.0 400 100,0
Central Java

Pekalongan City 400 400 100.0 400 100.0 400 100.0

Yogyakarta City 400 400 100.0 400 100.0 400 100.0
East Java

Sumenep 400 395 98.8 400 100.0 400 100.0

Madiun City 400 239 59.8 239 59.8 239 59.8
Surabaya City 400 400 100.0 400 100.0 400 100.0
Bali

Gianyar 400 44 11.0 45 11.3 45 11.3

Denpasar City 400 400 100.0 400 100.0 0 0.0
NTT

Kupang City 400 400 100.0 400 100.0 400 100.0

East Kalimantan

Balikpapan City 400 87 21.8 91 22.8 91 22.8

North Sulawesi
Manado City 400 400 100.0 399 99.8 399 99.8
South Sulawesi

Makassar City 400 400 100.0 400 100.0 400 100.0

Maluku

Maluku Tenggara Barat* 400 388 97.0 399 99.8 399 99.8
Papua

Jayapura City 400 367 91.8 400 100.0 400 100.0

Total 9600 8084 84.2 8149 84.9 7796 81.2 1600 100.0
Note:
Hepatitis B and C test was not done in these sites.

6.1 Socio-demographic Characteristics

The risk for HIV varies significantly with socio-demographic characteristics as factors that
influence individual’s risk behavior. From the total 9600 target respondents, the survey
succeeded in recruiting and interviewing 8084 respondents. This section describes the socio-
demographic characteristics of clients that consisted of survey venues, age, highest educational
level, identity card ownership, health insurance coverage and circumcision status. The

154
 information gained would be useful as input for development of health policies to address the
HIV/AIDS problem, specifically among high-risk population such as clients of sex workers.

6.1.1 Survey Venue

Overall the most common venue where clients for the survey could be identified was café/bar/
discotheque/pub/ karaoke bar (Table 6.2) (35.3%). This was similar to venues of FSWs, namely
cafe/ bar/discotheque/pub/karaoke bar. In each District/Municipality, the proportion varied, but
in most Districts/Municipalities (10 Districts/Municipalities) the most common venues for finding
clients were cafe/bar/discotheque/pub/karaoke bar. The highest proportion was in Madiun City
where all the client respondents were recruited in those venues (100.0%). The second most
common venue was by the roadside/in the park/cemetery/along the railway track. The aggregate
percentage was 20.3%, while at the District/Municipality level, the highest percentage was in
Jayapura City (56.9%), Yogyakarta City (51.5%) and Bekasi City (51.3%).

Clients who were identifed by the roadside/in the park/cemetery/along the railway track mostly
came from urban areas, which indicated that sex transaction venues in the urban area did not
differ much from venues in rural areas. The least common venue was dimly-lit food stall (3.9%),
and hotel/motel/cottage and rental room/house (4.0%). After café/bar, etc as the most common
venue, the survey venues of clients were slightly different from venues of FSWs. For FSWs, the
roadside/park/cemetery/railway track were the third most common venues, while for clients,
those were the second most common venues after cafe/bar/discotheque/pub/karaoke bar.
Venues that were the second most common for FSWs (salon, massage parlor) were number four
for clients. These venues would be useful information for programs that focus on client outreach.

Table 6.2 Survey Venues of Clients

Survey Venues of Clients (%)

District/Municipality n roadside/park/ Cafe/Bar/ Rental
Localization/ “dimly-lit” Hotel/Motel/ Salon/Massage
cemetery/ Discotheque/Pub Room/ Other
Brothel Food Stall Cottage Parlor
railway track / Karaoke Bar House

Bukittinggi City# 47 19.1 0.0 0.0 0.0 0.0 0.0 31.9 48.9

Ogan Komering Ulu 336 0.0 0.3 12.2 6.5 37.5 39.3 0.3 3.9
(OKU)
Pangkal Pinang City 400 15.8 3.8 8.5 0.3 23.5 0.5 0.0 47.8

Batam City 400 1.0 0.0 1.0 16.3 64.3 3.5 11.5 2.5

South Jakarta City 227 0.0 20.3 0.0 0.0 38.8 41.0 0.0 0.0

West Jakarta City 389 2.1 1.5 0.0 2.1 37.8 53.7 0.0 2.8

North Jakarta City 365 0.5 0.3 5.2 3.0 85.2 3.6 2.2 0.0

Bekasi 400 1.8 0.8 0.5 3.3 50.0 12.5 0.3 31.0

Sukabumi City 400 0.0 37.3 7.3 2.3 26.0 0.0 25.5 1.8

Bekasi City 400 1.5 51.3 4.0 0.0 5.3 30.5 5.0 2.5

Depok City 400 0.0 30.0 16.5 1.5 24.5 7.3 18.0 2.3

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 Survey Venues of Clients (%)
District/Municipality n roadside/park/ Cafe/Bar/ Rental
Localization/ “dimly-lit” Hotel/Motel/ Salon/Massage
cemetery/ Discotheque/Pub Room/ Other
Brothel Food Stall Cottage Parlor
railway track / Karaoke Bar House
Pekalongan City 400 18.3 46.0 17.5 0.0 18.3 0.0 0.0 0.0

Yogyakarta City 400 39.3 51.5 0.0 0.0 0.0 0.0 0.0 9.3

Sumenep 395 47.6 11.4 7.6 1.3 8.1 0.0 17.5 6.6

Madiun City 239 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0

Surabaya City 400 0.0 15.5 0.0 0.0 51.3 33.3 0.0 0.0

Gianyar# 44 0.0 0.0 36.4 0.0 61.4 2.3 0.0 0.0

Denpasar City 400 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Kupang City 400 20.0 0.0 0.0 26.0 54.0 0.0 0.0 0.0

Balikpapan City# 87 17.2 0.0 0.0 0.0 82.8 0.0 0.0 0.0

Manado City 400 0.5 28.0 0.0 2.0 54.5 1.3 0.0 13.8

Makassar City 400 0.0 0.0 0.0 15.8 56.3 28.0 0.0 0.0

Maluku Tenggara Barat 388 0.3 62.6 0.0 0.0 35.6 0.0 0.3 1.3

Jayapura City 367 1.1 56.9 0.3 0.0 0.0 0.0 0.0 41.7

Aggregate 7906 12.6 20.3 3.9 4.0 35.3 11.6 4.0 8.2
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

6.1.2 Age

Overall the median age of clients was 33 years (Table 6.3). In each District/Municipality the
median age varied, the youngest was 27.5 years in Sukabumi City and the oldest was 44 years in
Surabaya City. In almost half of the Districts/Municipalities, the median age was younger than the
aggregate median age, i.e. Batam City (30 years), South Jakarta City (29 years), West Jakarta City
(32 years), Sukabumi City (27.5 years), Bekasi City (32.5 years), Denpasar City (29 years), Kupang
City (32 years), Makassar City (31 years), Manado City and Maluku Tenggara Barat District (30
years).

Table 6.3 Age Group and Educational Level of Clients

Age Group (%) Educational level (%)

District/Municipality n Median Age Never Elementary Jr.High High
15-19 20-24 25-49 ≥50 College/
went to School/ Sch/ School/
years years years years University
school Equivalent Equivalent Equivalent
Bukittinggi City# 47 22 34.0 27.7 38.3 0.0 10.6 27.7 23.4 36.2 2.1

Ogan Komering Ulu (OKU) 336 34 0.0 7.1 87.2 5.7 1.2 11.9 25.0 57.1 4.8

Pangkal Pinang City 400 36 4.3 15.3 67.5 13.0 1.8 23.5 20.5 48.8 5.5

Batam City 400 30 1.8 20.5 74.0 3.8 0.5 5.0 10.3 80.8 3.5

South Jakarta City 227 29 7.9 24.2 59.0 8.8 0.9 7.0 17.2 64.8 10.1

West Jakarta City 389 32 3.6 20.3 69.7 6.4 0.3 5.4 15.2 73.8 5.4

North Jakarta City 365 35 4.4 12.3 72.1 11.2 2.7 21.4 23.3 49.9 2.7

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 Age Group (%) Educational level (%)
District/Municipality n Median Age Never Elementary Jr.High High
15-19 20-24 25-49 ≥50 College/
went to School/ Sch/ School/
years years years years University
school Equivalent Equivalent Equivalent
Bekasi 400 39 2.3 10.8 66.0 21.0 2.0 28.3 33.5 34.5 1.8

Sukabumi City 400 27.5 10.0 26.5 58.0 5.5 0.0 3.3 15.8 75.8 5.3

Bekasi City 400 32.5 1.3 10.5 85.5 2.8 0.3 2.8 19.0 62.3 15.8

Depok City 400 33 4.5 8.5 84.0 3.0 0.0 7.8 12.0 60.0 20.3

Pekalongan City 400 36 4.0 11.0 73.0 12.0 3.0 27.0 25.5 42.3 2.3

Yogyakarta City 400 42 3.5 15.5 50.0 31.0 1.8 29.3 23.3 37.5 8.3

Sumenep 395 34 0.5 7.8 85.8 5.8 1.0 3.3 9.4 51.6 34.7

Madiun City 239 33 2.9 26.4 50.6 20.1 1.3 8.8 19.7 66.5 3.8

Surabaya City 400 44 2.8 9.3 55.3 32.8 2.8 26.0 17.3 45.0 9.0

Gianyar# 44 35.5 6.8 4.5 72.7 15.9 4.5 20.5 18.2 45.5 11.4

Denpasar City 400 32 3.0 21.3 67.8 8.0 5.3 25.8 25.8 39.3 4.0

Kupang City 400 29 12.8 20.5 59.0 7.8 1.0 18.5 25.5 51.0 4.0

Balikpapan City# 87 29 4.6 24.1 63.2 8.0 1.1 4.6 6.9 78.2 9.2

Manado City 400 30 8.3 23.3 56.5 12.0 0.3 9.3 16.3 69.8 4.5

Makassar City 400 31 3.0 19.8 70.8 6.5 0.3 11.3 17.5 65.0 6.0

Maluku Tenggara Barat 388 30 7.5 21.9 64.4 6.2 1.0 2.6 8.5 63.4 24.5

Jayapura City 367 36 0.5 9.3 82.3 7.9 1.4 6.8 26.2 54.5 11.2

Aggregate 7906 33 4.2 16.0 68.8 10.9 1.4 13.2 19.3 65.5 9.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Most clients (68.8%) were older adults between 25 to 49 years old. The next largest group was
the young adult between the age of 20 to 24 (16.0%). In all Districts/Municipalities, the largest
proportion of clients were the older adults (25-49 years), followed by the young adults (20-24
years), and the ≥50-year age group. The smallest percentage of clients was the ≤15- to 19-year
age group except in Bekasi City, Pekalongan City and Yogyakarta City. In Kupang City, 12.8% of
clients were teenagers (≤15-19 years). A third of clients in Surabaya City and Yogyakarta City
were ≥50 years (32.8% and 31.0% respectively).

The age characteristic of clients was different from that of FSWs. In the client group, the ≤15- to
19-year age group was the smallest group, while among FSWs the smallest group was the older
age group at ≥50 years. This was because clients who were 15-19 years old would still be in school
and would not have money to pay sex workers.

6.1.3 Level of Education

The highest level of education of clients was defined as the education that clients completed or
for clients who was no longer in school, the level of education that clients started but not
completed. As an aggregate, as well as in all Districts/Municipalities, most clients completed high

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 school/equivalent (65.5%) while the smallest proportion was those who never went to school
(1.4%) (Table 6.3).

Clients with low educational level are at higher risk to be exposed to risky sexual behavior due to
lack of knowledge. In several Districts/Municipalities more than 10% of clients had higher
education (college/university). They were Sumenep District (34.7%), Maluku Tenggara Barat
District (24.5%), Depok City (20.3%), Bekasi City (15.8%) and Jayapura City (11.2%).

6.1.4 Marital Status

The marital status of clients was defined as a bond of marriage that is officially recognized by
tradition, law or religion. In the clients’ group, marital status was categorized into three groups:
unmarried, married (married and living with the spouse, married and living separately from the
spouse), divorced (divorced and widowed). Overall, more than half (58.8%) of clients were
married (Table 6.4), and the same percentage was seen in all Districts/Municipalities except in
Kupang City where the most common status was unmarried (57.0%). The highest proportion of
married clients was found in Bekasi City (76.3%) and the lowest was found in Yogyakarta City
(49.0%). The highest proportion of unmarried clients was found in Kupang City (57.0%), and the
lowest was found in Bekasi City (18.3%). One interesting finding was that divorced clients were
the smallest proportion (7.5%).

Table 6.4 Marital Status, Circumcision Status and Health Insurance Coverage of Clients

Marital Status (%) Circumcision Health Insurance

District/Municipality n
Unmarried Married Divorced Status (%) Coverage (%)

Bukittinggi City# 47 80.9 12.8 6.4 97.9 25.5

Ogan Komering Ulu (OKU) 336 22.6 56.8 20.5 99.7 38.4
Pangkal Pinang City 400 30.8 61.0 8.3 93.8 68.8
Batam City 400 33.0 63.5 3.5 89.5 80.5
South Jakarta City 227 41.0 54.2 4.8 99.6 69.2
West Jakarta City 389 35.0 58.1 6.9 96.7 73.8
North Jakarta City 365 29.3 59.7 11.0 99.2 80.0
Bekasi 400 18.3 76.3 5.5 99.8 49.0
Sukabumi City 400 46.5 51.5 2.0 100.0 62.8
Bekasi City 400 29.5 62.3 8.3 96.5 77.5
Depok City 400 36.0 54.5 9.5 89.0 77.0
Pekalongan City 400 29.8 64.8 5.5 100.0 77.3
Yogyakarta City 400 35.8 49.0 15.3 98.5 65.3
Sumenep 395 18.5 74.9 6.6 99.5 57.2
Madiun City 239 41.4 53.1 5.4 99.6 71.1
Surabaya City 400 18.8 71.5 9.8 98.8 65.0
Gianyar# 44 43.2 52.3 4.5 29.5 59.1
Denpasar City 400 36.8 50.3 13.0 73.0 48.8
Kupang City 400 57.0 40.3 2.8 49.5 49.5

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 Marital Status (%) Circumcision Health Insurance
District/Municipality n
Unmarried Married Divorced Status (%) Coverage (%)

Balikpapan City# 87 46.0 41.4 12.6 90.8 81.6

Manado City 400 41.5 54.0 4.5 44.5 74.5
Makassar City 400 41.8 54.3 4.0 93.5 62.5
Maluku Tenggara Barat 388 39.4 58.8 1.8 29.1 64.4
Jayapura City 367 28.6 63.2 8.2 45.5 75.2

Aggregate 7906 33.7 58.8 7.5 84.9 66.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The result shows that being married was not the criteria for clients to remain faithful to their
spouse, especially since 51.0% of clients were married and were living with their spouse. The
situation was different with FSWs who were mostly already divorced. In fact, being divorced was
probably the reason why a woman decided to go into sex work as she needed to make a living
and, for women who have children, to provide for her family. Clients who were divorced would
not be bound to a spouse and would be free to have sex with FSWs, but findings showed that few
clients who bought sex from sex workers were actually divorced (Table 6.4).

6.1.5 Circumcision Status

Circumcision is one way to prevent HIV infection. As seen in Table 6.4, the majority of clients
(84.9%) were circumcised. The highest was among clients in Sukabumi City and Pekalongan City
(100.0%), but in several Districts/Municipalities less than 50% of clients were circumcised, like
in Jayapura City (45.5%), Maluku Tenggara Barat District (29.1%), Manado City (44.5%) and
Kupang City (49.5%). This was because the majority of population in those
Districts/Municipalities were non-muslim, while circumcision is a teaching of Islam.

A previous study that followed 137 men for 30 months reported that among 50 circumcised men,
no new HIV cases were detected, while among the uncircumcised men, 40 new HIV cases were
diagnosed. The two groups received the same interventions, were given free condom, free HIV
test and counseling (Szabo R. & Short, Roger V, 2000). Circumcision is also able to prevent
transmission of Syphilis and Gonorrhea (Cook LS, Koutsky LA, & Holmes KK, 1994).

6.1.6 Health Insurance Coverage

Health insurance is one indicator that is used to indirectly measure client’s access to health care.
The survey found that 66.6% of clients had health insurance (Table 6.4). In this section the
information is presented only as two categories: had health insurance or did not have health
insurance. Information on the type of insurance, whether it was public (BPJS) or private
insurance, was not available. The highest proportion of clients with health insurance coverage
was in Batam City (80.5%) and the lowest was in Ogan Komering Ulu (OKU) District (38.4%).
Having health insurance coverage is linked with client’s access to health care.

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 6.2 Knowledge about HIV/AIDS, Its Risk, and Prevention
Knowledge is the result of “knowing”, which an individual has after he/she experiences a certain
object through seeing, smelling, hearing and touching. Cognitive knowledge is critical in shaping
someone’s action (Notoatmodjo, 2007). The more information is received, the more
knowledgeable a person becomes. It is therefore important that clients as a high-risk group for
HIV/AIDS infection, have good knowledge about HIV/AIDS. It is hoped that the knowledge will
influence their sexual practices and they can adopt protective and preventive behavior. The
HIV/AIDS information that the survey tried to explore was information on prevention of
HIV/AIDS, source of information, misconception, risk perception and prevention.

6.2.1 Knowledge about HIV/AIDS

Knowledge influences one’s attitude and practices, eventhough good knowledge does not always
result in good practices. For clients, it is hoped that those with good knowledge on HIV/AIDS will
adopt safe sexual practices. This survey looked at client’s knowledge about prevention of
HIV/AIDS, and several misconceptions around HIV/AIDS. The information was then combined
into one overall variable of comprehensive knowledge.

A client was defined as having comprehensive knowledge based on knowledge about three types
of information. First, they knew about HIV/AIDS prevention (always use condom during sex and
be faithful to one’s partner). Second, they knew how HIV is transmitted (they answered correctly
that HIV is not transmitted by mosquito/insect bite or through sharing eating utensils). Three,
clients knew that someone who looks healthy can still be infected with HIV. The survey found that
client’s level of comprehensive knowledge on HIV/AIDS was still very low (16.1%) (Table 6.5).

The lowest level of comprehensive knowledge was found in Sukabumi City (2.3%) and the highest
was found in Bekasi City (38.3%). The most commonly known type of information was that
HIV/AIDS can be prevented by being faithful to one’s partner (68.6%) and by using condom
(66.3%). The least known information was about HIV not being transmitted through food
(44.4%). In other words, more than half of clients believed that HIV can spread through sharing
food. Less than half (45.8%) of clients knew that HIV is not transmitted by mosquito/insect bite
(Table 6.5).

Table 6.5 Clients’ Knowledge about HIV/AIDS, Risk Perception, and Protective Behavior

Knowledge about HIV (%) Protective Behavior to

Prevent HIV Infection
Prevention of HIV Transmission of HIV (%)
A healthy- Comprehensive Risk
District/ Municipality n looking HIV is not HIV is not Knowledge Perception
individual Always transmitted transmitted (%)* (%) Always Be faithful Not
Be faithful
can be HIV- use through through use to sex sharing
to partner
infected condom mosquito/ sharing condom partner needle
insect bite food

Bukittinggi City# 47 23.4 38.3 42.6 34.0 36.2 8.5 21.3 55.3 27.7 51.1

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 Knowledge about HIV (%) Protective Behavior to
Prevent HIV Infection
Prevention of HIV Transmission of HIV (%)
A healthy- Comprehensive Risk
District/ Municipality n looking HIV is not HIV is not Knowledge Perception
individual Always transmitted transmitted (%)* (%) Always Be faithful Not
Be faithful
can be HIV- use through through use to sex sharing
to partner
infected condom mosquito/ sharing condom partner needle
insect bite food
Ogan Komering Ulu 336
26.8 62.5 69.6 45.5 48.8 17.9 19.3 51.2 58.3 42.0
(OKU)
Pangkal Pinang City 400 23.5 47.0 49.0 45.5 44.5 13.3 28.3 60.8 47.5 36.0
Batam City 400 68.3 72.0 61.3 51.8 51.0 24.5 60.0 88.8 58.0 28.5
South Jakarta City 227 58.1 71.8 71.4 48.9 45.8 18.5 38.8 58.6 94.7 52.4
West Jakarta City 389 38.0 79.2 83.5 56.6 38.8 5.4 54.5 91.5 74.6 48.1
North Jakarta City 365 41.4 57.5 60.3 47.9 47.9 15.6 44.4 83.0 76.7 61.6
Bekasi 400 34.3 58.3 65.5 43.3 42.8 6.5 53.3 73.3 76.0 27.0
Sukabumi City 400 19.3 27.3 26.8 33.8 31.0 2.3 6.5 26.8 23.3 7.5
Bekasi City 400 60.5 77.8 75.8 52.5 60.8 38.8 30.5 68.0 66.8 74.3
Depok City 400 53.8 73.8 80.8 44.5 45.0 23.0 22.5 63.0 62.3 48.8
Pekalongan City 400 60.3 86.5 91.8 33.5 37.0 10.5 32.3 85.8 82.0 69.0
Yogyakarta City 400 66.3 78.0 79.0 53.3 54.5 28.0 45.3 94.3 80.8 75.3
Sumenep 395 56.2 65.3 62.8 61.3 58.5 24.3 20.3 94.9 77.0 42.0
Madiun City 239 63.6 72.4 78.2 51.0 45.2 15.5 27.6 72.4 90.0 51.5
Surabaya City 400 53.8 71.0 79.0 26.8 32.3 9.3 34.0 88.8 92.3 77.8
Gianyar# 44 31.8 65.9 70.5 45.5 52.3 2.3 47.7 84.1 75.0 54.5
Denpasar City 400 51.5 62.3 66.3 50.0 55.8 18.5 70.3 93.3 51.8 37.0
Kupang City 400 45.8 80.8 87.5 38.5 45.0 16.0 50.3 75.3 62.5 60.3
Balikpapan City# 87 58.6 71.3 63.2 32.2 39.1 13.8 42.5 87.4 78.2 48.3
Manado City 400 30.3 75.0 79.3 36.5 43.8 7.8 27.5 53.8 52.0 40.0
Makassar City 400 21.0 26.8 24.8 15.0 14.5 7.5 29.3 48.5 27.0 45.5
Maluku Tenggara
388 57.2 68.0 71.4 54.4 52.1 17.8 10.8 67.3 78.1 41.2
Barat
Jayapura City 367 69.2 85.0 82.8 77.9 39.8 17.4 81.7 91.0 45.2 26.2

Aggregate 7906 47.1 66.3 68.6 45.8 44.4 16.1 37.6 73.5 64.5 47.1
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *A composite
variable of knowledge about HIV/AIDS prevention (always use condom in sexual intercourse and be faithful to one’s partner); HIV
transmission (HIV is not transmitted through mosquito/insect bite or through sharing eating utensils); and knowledge that a healthy-
looking individual can be HIV-infected.

Districts/Municipalities with the highest proportion of clients who knew about HIV prevention
methods (use condom and be faithful to one’s partner) were Pekalongan City (91.8% and 85.6%),
Kupang City (87.5% and 80.8%) and Jayapura City (82.8% and 85.8%). The lowest proportion of
clients with knowledge about prevention methods was found in Makassar City (24.8% and
26.8%) and Sukabumi City (26.8% and 27.3%). The highest proportion of clients who correctly
stated that HIV/AIDS is not transmitted by mosquito/insect bites or by sharing eating utensils
was found in Sumenep District (61.3% and 58.5% respectively) and the lowest proportion was

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found in Surabaya City (26.8% and 32.3%). Less than half (47.1%) of clients knew that a healthy-
looking person can be HIV-infected (Table 6.5).

The proportion of clients with comprehensive knowledge about HIV was similar to the proportion
of comprehensive knowledge among FSWs, at around 16%. The highest proportion of knowledge
on HIV prevention for both clients and FSWs was found in Kupang City and Jayapura City. This
indicated that FSW’s and client’s knowledge about HIV prevention was already quite good. The
low level of comprehensive knowledge among clients needs special attention, and efforts need to
be made to improve client’s knowledge as one group who is at high risk for HIV infection.
Inadequate knowledge will influence client’s sexual behavior that results in HIV and STI infection.

6.2.2 Risk Perception for HIV Infection and Protective Behavior

The proportion of clients who felt at risk of HIV infection was very small at 37.6%. This meant
that more than half of FSW’s clients did not feel at risk of HIV infection. The highest risk
perception was found in Denpasar City (70.5%) and the lowest was found among clients in
Sukabumi City (6.5%). This was different from FSWs where the lowest risk perception was found
in Sumenep District (23.8%). Protective behavior of clients to prevent HIV infection consisted of
always using condom (73.5%), being faithful to their partner (64.5%) and not sharing used
injection needles (47.1%).

The majority of clients who stated they always used condom to protect themselves were in
Sumenep District (94.9%) and the lowest proportion was found in Sukabumi City (26.8%). Those
who stated they prevented HIV infection by being faithful to one’s partner were primarily found
in South Jakarta City (94.7%) and the lowest proportion was also found in Sukabumi City (23.3%).
The highest proportion of those who did not share injection needles was found in Surabaya City
(77.8%) while the lowest proportion was also in Sukabumi City (7.5%). Based on this finding,
clients in Sukabumi City had the lowest level of comprehensive knowledge, and least knowledge
about HIV prevention. They also adopted minimum protective behavior, and had the lowest risk
perception.

6.2.3 Reason Clients Feel At Risk of HIV Infection

Clients who stated that they feel at risk of HIV infection were asked for the reason. The question
had multiple answers, and clients could select more than one answer. The result is summarized
in Table 6.6. The majority of clients stated that they felt at risk because they had engaged in
unprotected sex (91.8%).

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 Table 6.6 Reasons Clients Feel At Risk of HIV Infection

Reasons for Feeling At Risk of HIV Infection (%)

District/Municipality n*
Received blood
Had used drugs Had unprotected sex Other
transfusion
Bukittinggi City# 10 60.0 90.0 0.0 0.0
Ogan Komering Ulu (OKU) 65 3.1 46.2 50.8 4.6
Pangkal Pinang City 113 11.5 94.7 6.2 0.9
Batam City 240 41.3 93.3 17.5 1.7
South Jakarta City 88 9.1 93.2 9.1 0.0
West Jakarta City 212 8.5 96.2 5.2 0.9
North Jakarta City 162 28.4 94.4 29.6 2.5
Bekasi 213 6.6 93.4 16.0 0.5
Sukabumi City 26 0.0 88.5 3.8 7.7
Bekasi City 122 5.7 96.7 4.9 7.4
Depok City 90 10.0 86.7 3.3 1.1
Pekalongan City 129 40.3 98.4 18.6 0.0
Yogyakarta City 181 17.1 70.2 31.5 2.8
Sumenep 80 17.5 93.8 18.8 0.0
Madiun City 66 3.0 84.8 0.0 16.7
Surabaya City 136 39.0 90.4 37.5 11.8
Gianyar# 21 9.5 90.5 28.6 4.8
Denpasar City 281 4.6 94.3 4.3 10.0
Kupang City 201 1.0 99.0 2.5 11.9
Balikpapan City# 37 0.0 94.6 2.7 0.0
Manado City 110 3.6 76.4 2.7 2.7
Makassar City 117 0.0 98.3 9.4 0.0
Maluku Tenggara Barat 42 9.5 54.8 14.3 14.3
Jayapura City 300 2.0 95.7 4.7 0.0

Aggregate 2974 13.3 91.8 13.1 4.0

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of clients
who feel at risk of HIV infection

Other clients answered that they had used drugs in the past (13.3%) and some others mentioned
that they had received blood transfusion (13.1%), but in all Districts/Municipalities, the most
common reason for feeling at risk was unsafe sex. An exception were clients in Ogan Komering
Ulu (OKU) District (46.2%). Clients’ knowledge about HIV prevention was in line with their risk
perception. Most clients mentioned condom use as one action they did to prevent HIV. They did
that since most clients also felt at risk due to the unsafe sex that they had done.

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6.3 Sexual Behavior and Prevention
FSW’s clients are one group who is at risk of HIV/AIDS. People with high-risk behavior are at risk
of getting HIV as well as transmitting HIV to other people. The Decree of the Coordinating Minister
for People's Welfare Number 9/1994 states that one target for HIV/AIDS information, education
and communication (IEC) was high-risk groups, namely people whose occupation caused them to
be at higher risk of getting and transmitting HIV. Sex workers and clients of FSWs are one
example.

Early precaution to prevent HIV transmission among clients is of utmost importance since there
can be a chain of transmission from clients to FSWs, to clients’ partner or family, to other sex
partner, to the community and other FSWs. This section presents information on sexual behavior
of clients that included age at first vaginal sex, age at first anal sex, age at first time buying sex
from FSWs, presence of a steady partner, condom use, condom use consistency, and number of
visits to FSW in the last six months. Efforts to prevent sexual transmission of HIV have been
hampered by a number of constraints that include lack of guaranteed government funding for
condom provision, lack of supportive policies, strong societal rejection of condom as a prevention
method and limited promotion about condom use to the public (NAC, 2010).

6.3.1 Sex Partner and Condom Use

The risk for STI and HIV/AIDS among clients increases with each additional sex partner they have.
The 2018-2019 IBBS looked at two types of sex partners that clients had: their steady partner,
and female sex workers (FSWs). Clients are FSW’s paying sex partner (monetary or non-monetary
payment). Steady sex partner is a sex partner who a client acknowledges as a willing sex partner
in a committed relationship that has lasted for at least three months.

The IBBS looked at condom use during client’s last sex with each of the partner, consistency in
condom use in the last month, and the number of visits a client made to FSW in the last six months.
Condom can prevent STI and HIV infection, or reduce the risk of transmission, eventhough it
cannot 100% prevent transmission. An individual’s sexual behavior, including condom use
behavior, is influenced by a number of factors. A theory proposed by Green states that the most
important matter in health behavior is shaping the process of behavior change. Green theorizes
that an individual’s behavior is shaped by three different factors. Each factor has a different
influence. It can predispose an individual toward a certain behavior change (predisposing
factors), enable an individual to make a change (enabling factors), and reinforce the change
(reinforcing factors) (Green et al., 2002).

Predisposing factors of condom use by clients were knowledge about STI and HIV/AIDS, and
client’s attitude toward condom use. Enabling factors included access to information about STI

164
 and HIV/AIDS, while reinforcing factors were client’s perception of their ability to adopt safe sex
behaviors plus support from pimps regarding condom use (Budiono, 2012).

6.3.1.1 Sexual Behavior and Condom Use Consistency with a Steady Partner
Overall, more than 70% of clients had a steady partner (78.9%). In few sites, the proportion of
clients with a steady partner was less than 70%. They were Madiun City (66.6%), Kupang City
(62.0%) and Makassar City (57.0%). The highest proportion of clients with a steady partner
(93.0%) was found in South Jakarta (Table 6.7).

In the survey, clients with a steady partner were asked about condom use when they last had sex
with their steady partner. Overall the percentage of condom use was 13.7%. The highest was in
Yogyakarta City (38.5%) and the lowest was in Makassar City (1.3%). This low level of condom
use was probably because clients felt safe with their steady partner, and were not worried about
STI or HIV. They believed their steady partner did not have STI or HIV/AIDS. Another reason was
also because clients did not feel they could infect their steady partner and condom use might
make the steady partner feel suspicious.

Table 6.7 Client’s Sexual Behavior, Condom Use Consistency with Steady Partner and FSWs and Number of Visit to FSWs in
the Last Six Months
Used Condom with FSW
Used Condom in Last Had Sex with (%) Ave # of Visit
Has a Steady Sex among Clients FSWs in the to FSW in the
District/Municipality n Partner who Have a Steady Used condom Used condom
Last Month Last 6 Months
(%) Partner during last consistently in
(%)* (%) (%)
sex the last month**

Bukittinggi City# 47 36.2 23.5 74.5 60.0 45.7 3

Ogan Komering Ulu (OKU) 336 79.5 9.7 34.2 63.5 48.7 3

Pangkal Pinang City 400 80.3 10.3 35.8 48.3 25.2 2

Batam City 400 82.8 22.1 81.3 64.0 45.8 3

South Jakarta City 227 93.0 14.2 78.0 43.5 26.0 2

West Jakarta City 389 84.1 13.8 72.0 77.1 73.6 3

North Jakarta City 365 75.3 8.4 49.0 54.7 48.0 2

Bekasi 400 91.3 10.4 78.3 35.8 19.5 3

Sukabumi City 400 87.0 4.9 56.0 28.6 12.5 3

Bekasi City 400 75.5 22.2 55.0 53.2 35.0 3

Depok City 400 75.5 17.5 85.8 53.4 38.2 5

Pekalongan City 400 80.8 7.1 32.5 27.7 11.5 3

Yogyakarta City 400 89.5 38.5 35.5 66.9 58.5 2

Sumenep 395 77.5 9.2 78.7 74.9 61.7 3

Madiun City 239 66.5 12.6 46.4 18.0 10.8 2

Surabaya City 400 78.0 11.2 74.5 41.3 25.5 3

Gianyar# 44 90.9 20.0 59.1 46.2 23.1 5

Denpasar City 400 72.8 13.1 73.8 78.0 67.5 4

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 Used Condom with FSW
Used Condom in Last Had Sex with (%) Ave # of Visit
Has a Steady Sex among Clients FSWs in the to FSW in the
District/Municipality n Partner who Have a Steady Used condom Used condom
Last Month Last 6 Months
(%) Partner during last consistently in
(%)* (%) (%)
sex the last month**

Kupang City 400 62.0 16.5 72.5 52.4 37.9 3

Balikpapan City# 87 89.7 12.8 40.2 11.4 5.7 1

Manado City 400 84.3 17.8 25.0 34.0 13.0 2

Makassar City 400 57.0 1.3 98.3 49.6 7.1 4

Maluku Tenggara Barat 388 78.4 5.3 4.1 25.0 18.8 1

Jayapura City 367 87.5 19.0 92.1 49.4 27.2 3

Aggregate 7906 78.9 13.9 60.0 48.1 35.8 3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among clients
who had a steady partner; **Among clients who bought sex from FSW in the last month.

6.3.1.2 Sexual Behavior and Condom Use Consistency with FSW

As an aggregate 60.0% of clients had sex with an FSW in the last month (Table 6.7). The highest
proportion was in Makassar City (98.3%) and the lowest was in Maluku Tenggara Barat District
(4.1%). In almost 50% of Districts/Municipalities, the proportion of clients who visited FSWs in
the last month was higher than 70%. However, less than 50% of clients (48.1%) used condom in
their last sex with an FSW, as an aggregate, as well as in most Districts/Municipalities. The highest
condom use was in Denpasar City (78.0%) and the lowest was in Madiun City (18.0%).
Eventhough condom use with FSWs was higher than condom use with a steady partner, the actual
proportion was still low.

As an aggregate, only a third of clients (35.8%) used condom consistently with FSWs in the last
month. The highest was in West Jakarta (73.6%) and the lowest was in Makassar City (7.1%).
Compared to other Districts/Municipalities, condom use in Makassar City had been the lowest,
during last sex with FSWs, during last sex with a steady partner, and also in terms of condom use
consistency. The majority of clients in Makassar City (98.3%) perceived themselves to be at risk
of HIV infection, but actual condom use was very low.

The way an individual perceives his likelihood to get a disease will influence his behavior, which
will primarily be efforts to prevent the disease or to seek treatment. If there is a great likelihood
that this individual may get the disease, then he/she will quickly feel threatened, and will quickly
take preventive actions. Someone’s sense of vulnerability depends on how much risk they
perceive they will face in any given situation (Jane Ogden, 1996; Solita Sarwono, 2007). Contrary
to that understanding, this survey found that eventhough the majority of clients felt at risk of
getting HIV/AIDS, only a small proportion adopt any protective behavior to prevent infection by
consistently using condom. This showed that risk perception does not always result in good
sexual practices.

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 Consistent condom use is one of six protective behaviors for preventing HIV. Condom is
particularly necessary during risky sexual behavior or with a HIV-positive and/or STI-positive
partner (MOH RI, 2013). Consistent condom use can prevent HIV infection and widespread
transmission of HIV. It is a comprehensive and sustainable approach to prevent HIV and STI, and
condom will have maximum effect if it is used consistently for every sexual encounter, not just
occasionally (Ali, Mohammed S. et al., 2019). An individual with higher level of education has a
tendency to be more consistent in using condom (Dessie, Y et al., 2011). This is in line with the
result of this survey how the proportion of condom use consistency increased as clients’
educational level increased. Clients with a university degree used condom more consistently than
clients with a lower level of education (33.0%). Efforts to increase client’s condom use and its
consistency can therefore be done by increasing client’s knowledge about condom, HIV and STI.

6.3.2 Average Number of Visit to FSW in the Last Six Months

The more frequent a client buys sex from FSW, the more sexual transactions are taking place, and
the higher the risk is for HIV/AIDS and STI transmission. The survey asked clients how many
times they bought sex in the last six months, and on average they said three times. The most
frequent was five times and that was stated by clients in Depok City. The least frequent was in
Maluku Tenggara Barat District, which was one time. Clients who bought sex five times may also
have sex with different FSWs, which would place them at higher risk of getting HIV and STI than
clients who only bought sex once.

6.3.3 Reason for Not Using Condom during Last Sex with FSW

Reasons clients stated for not using condom in their last sex with FSW were summarized in Table
6.8. Discomfort/reduced pleasure was the most common reason (51.0%), and the majority of
clients who mentioned that was found in Pekalongan City (80.6%). This finding was similar to the
finding with FSWs who claimed that their clients requested to not use condom as it reduced their
comfort/pleasure. The largest proportion of FSWs who stated that reason was also found in
Pekalongan City. The next most common reason was condom inavailability (32.7%) and it was
mostly found in Sumenep District (83.2%).

Table 6.8 Client’s Reason for Not Using Condom during Last Sex with FSW

Reason for Not Using Condom during Last Sex with FSW (%)

District/Municipality n* Condom Felt clean / Don’t know/ Uncomfortable I have No regulation

FSW
not had taken don’t / not paid for that mandates Other
refused
available medicine remember pleasurable sex condom use

Bukittinggi City# 19 15.8 0.0 5.3 21.1 84.2 0.0 0.0 0.0
Ogan Komering Ulu (OKU) 237 42.6 5.9 5.5 11.4 26.2 5.5 5.1 15.2
Pangkal Pinang City 213 16.4 2.3 1.4 13.6 38.5 3.8 6.6 0.0

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 Reason for Not Using Condom during Last Sex with FSW (%)

District/Municipality n* Condom Felt clean / Don’t know/ Uncomfortable I have No regulation

FSW
not had taken don’t / not paid for that mandates Other
refused
available medicine remember pleasurable sex condom use

Batam City 143 19.6 2.1 9.1 26.6 55.2 6.3 0.7 1.4
South Jakarta City 142 17.6 7.0 34.5 15.5 36.6 4.9 10.6 0.7
West Jakarta City 114 18.4 2.6 12.3 41.2 55.3 7.9 0.9 2.6
North Jakarta City 152 11.2 6.6 19.7 21.7 65.8 8.6 2.6 2.0
Bekasi 268 41.8 22.4 38.4 31.0 46.6 10.1 8.6 0.4
Sukabumi City 282 9.2 3.5 2.5 5.0 59.6 3.9 2.1 0.0
Bekasi City 157 25.5 2.5 33.1 19.1 73.9 15.3 8.3 0.6
Depok City 194 72.2 3.6 12.9 30.4 57.2 11.9 7.2 0.0
Pekalongan City 268 67.5 17.9 41.8 60.4 80.6 39.9 61.9 0.0
Yogyakarta City 136 36.8 22.1 52.2 48.5 64.0 24.3 30.1 2.9
Sumenep 119 83.2 32.8 21.0 16.0 37.8 4.2 5.0 0.0
Madiun City 188 22.3 0.5 1.1 25.0 64.9 6.4 1.6 2.7
Surabaya City 237 53.2 10.5 52.3 28.7 79.3 24.1 24.5 2.1
Gianyar# 17 35.3 41.2 17.6 11.8 82.4 23.5 29.4 5.9
Denpasar City 99 18.2 11.1 27.3 10.1 70.7 2.0 0.0 5.1
Kupang City 196 39.3 13.8 50.0 43.9 75.0 48.5 30.1 2.0
Balikpapan City# 70 37.1 0.0 7.1 12.9 62.9 5.7 1.4 5.7
Manado City 301 16.3 2.7 15.9 20.6 14.6 3.3 4.7 1.0
Makassar City 202 11.4 0.5 50.5 15.8 45.5 29.2 11.9 0.0
Maluku Tenggara Barat 255 26.7 5.9 13.3 20.8 9.8 0.4 0.0 10.6
Jayapura City 198 31.3 3.5 15.7 8.6 49.0 33.3 8.1 0.0

Aggregate 4101 32.7 8.2 24.0 24.5 51.0 14.4 11.9 2.4
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of clients
who did not use condom during their last sex with FSW.

Some clients also said they did not use condom as they felt clean/had taken medicine (24.0%),
and a similar proportion cited lack of knowledge (24.5%). There were also clients (14.4%) who
stated that pleasure was the primary reason they bought sex and since they had already paid for
sex, they demanded pleasure while condom reduced the sensation or sexual pleasure. Use of
condom is not simply for preventing pregnancy but also to prevent transmission of diseases like
STI and HIV/AIDS.

6.3.4 Age at First Vaginal Sex

As an aggregate the median age of first vaginal sex among clients was 20 years (Table 6.9). The
youngest was 18 which was found in three cities: Kupang City, Manado City and Jayapura City.
The oldest was 23 years in Pekalongan City, which was actually still relatively young to be

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 sexually-active. The most common age range for first vaginal sex among clients was 18-24 years.
More than half (51.3%) of clients had their first experience with vaginal sex in this age range. The
second most common age group was ≥25 years (16.2%) and the adolescence period between 15-
17 years old (15.3%). There was also about 15.9% of clients who did not remember when they
first had vaginal sex.

At the District/Municipality level, the largest proportion of clients who first experienced vaginal
sex between the age of 18 to 24 was found in Jayapura City (68.9%) and Depok City (68.7%). The
largest proportion of clients whose sexual debut started at ≥25 years was in Pekalongan City
(33.3%). A small proportion of clients (1.2%) had an early vaginal sexual debut at ≤14 years
(Table 6.9), and the largest proportion was found in Denpasar City (4.8%). This is a very young
age that makes the individuals highly vulnerable to risky sexual behavior. In most
Districts/Municipalities, the proportion of clients with early sexual debut (≤14 years old) was
below 1%. Analysis revealed that among clients who started sex very early, the smallest
proportion was those with higher education (university level) (0.5%). Individuals who started
sex at a very early age may also be inclined to have multiple sex partners (Felton CG, 2003).

6.3.5 Age at First Anal Sex

Overall, the median age of first anal sex among clients was 20 years (Table 6.9). This was the same
as the median age for first vaginal sex. The youngest, at 17 years, was found in Ogan Komering
Ulu (OKU) District. In more than half of the Districts/Municipalities, the median age of first anal
sex was younger than the aggregate median age. The oldest was at 26.5 years in Depok City. More
than half of the clients (57.3%) also did not remember when they first had anal sex, higher than
the percentage who did not remember their first vaginal sex experience, indicating that clients
tended to remember their vaginal sex experience more than anal sex. The most common age for
first anal sex among clients was between 18 to 24 years (23.8%), followed by ≥25 years (10.8%).

Table 6.9 Age of First Vaginal and Anal Sex among Clients
Age at
Age at First Age at First Vaginal Sex in Years Age at First Anal Sex in Years
First Anal
Vaginal Sex (%) (%)
District/Municipality n* n** Sex
Do not Do not
Median ≤ 14 15 - 17 18 - 24 ≥ 25 Median ≤ 14 15 - 17 18 - 24 ≥ 25
remember remember
Bukittinggi City# 46 16 19.6 50.0 21.7 2.2 6.5 11 19 0.0 27.3 27.3 9.1 36.4
Ogan Komering Ulu
297 21 0.0 8.8 26.9 15.5 48.8 125 17 0.0 19.2 14.4 0.8 65.6
(OKU)
Pangkal Pinang City 365 22 0.0 5.8 27.1 15.6 51.5 81 20 0.0 4.9 8.6 4.9 81.5
Batam City 391 20 0.5 8.2 57.3 16.4 17.6 43 21 0.0 0.0 14.0 7.0 79.1
South Jakarta City 225 19.5 0.4 23.6 55.1 13.3 7.6 17 19 5.9 5.9 35.3 5.9 47.1
West Jakarta City 384 20 0.3 11.7 60.2 16.9 10.9 10 18 10.0 10.0 30.0 0.0 50.0
North Jakarta City 360 20 0.8 20.0 50.0 22.5 6.7 11 19 0.0 18.2 45.5 0.0 36.4
Bekasi 393 21 1.0 9.9 37.7 19.8 31.6 169 20 0.0 4.1 8.9 4.1 82.8

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 Age at
Age at First Age at First Vaginal Sex in Years Age at First Anal Sex in Years
First Anal
Vaginal Sex (%) (%)
District/Municipality n* n** Sex
Do not Do not
Median ≤ 14 15 - 17 18 - 24 ≥ 25 Median ≤ 14 15 - 17 18 - 24 ≥ 25
remember remember
Sukabumi City 393 20 0.0 9.7 63.1 3.1 24.2 112 18 0.0 1.8 2.7 0.0 95.5
Bekasi City 399 20 0.3 12.3 55.1 8.3 24.1 200 19 0.0 5.0 47.0 0.5 47.5
Depok City 399 20 0.0 17.8 68.7 11.8 1.8 30 26.5 3.3 3.3 23.3 56.7 13.3
Pekalongan City 393 23 0.5 7.1 37.9 33.3 21.1 30 18 10.0 10.0 16.7 3.3 60.0
Yogyakarta City 398 20 3.3 11.8 39.7 16.8 28.4 56 26 1.8 1.8 3.6 12.5 80.4
Sumenep 395 22 0.0 3.0 48.4 42.3 6.3 136 25 0.0 0.7 16.9 43.4 39.0
Madiun City 239 20 0.4 20.1 58.2 20.1 1.3 2 18.5 0.0 50.0 50.0 0.0 0.0
Surabaya City 399 21 1.5 16.3 54.9 27.1 0.3 15 26 0.0 13.3 26.7 60.0 0.0
Gianyar# 44 18 2.3 25.0 54.5 6.8 11.4 8 19 0.0 12.5 12.5 12.5 62.5
Denpasar City 395 19 4.8 20.8 61.0 10.4 3.0 22 25 0.0 4.5 22.7 40.9 31.8
Kupang City 397 18 4.0 32.0 53.4 3.8 6.8 24 18 4.2 20.8 29.2 8.3 37.5
Balikpapan City# 85 18 3.5 30.6 41.2 12.9 11.8 13 22 0.0 0.0 61.5 23.1 15.4
Manado City 388 18 4.1 43.0 45.6 6.4 0.8 19 18 5.3 31.6 47.4 5.3 10.5
Makassar City 400 20 0.3 7.8 51.3 15.5 25.3 21 18 4.8 14.3 23.8 0.0 57.1
Maluku Tenggara Barat 292 20 2.1 12.0 54.8 19.2 12.0 60 21 0.0 5.0 36.7 16.7 41.7
Jayapura City 366 18 0.5 24.0 68.9 3.3 3.3 91 20 2.2 15.4 61.5 5.5 15.4

Aggregate 7668 20 1.2 15.3 51.3 16.2 15.9 1274 20 0.9 7.2 23.8 10.8 57.3
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of clients
who have had vaginal sex with missing data taken out; ** Number of clients who have had anal sex with missing data taken out

Anal sex was actually not very common among clients. Overall only 16% of clients ever had anal
sex. The largest number was in Bekasi City (200 people) and the smallest number was in Madiun
City (2 people). In most Districts/Municipalities, no clients started anal sex at 14 or younger. The
highest percentage at 10.0% was found in West Jakarta and Pekalongan City. The largest
proportion of clients started anal sex at the same age as vaginal sex which was between 18 to 24,
followed by age 25 or older. Those who started anal sex at a very young age (≤14 years) was 0.9%,
less than the proportion who started vaginal sex at that age (1.2%). The majority of clients whose
sexual debut (vaginal and anal sex) started very early was found in West Jakarta City.
An individual’s sexual behavior is very much influenced by attitudes, like and dislike, or approval
and disapproval, which are established through comprehensive knowledge about sex. In other
words, a teen’s intention to adopt a certain sexual behavior, irrespective of the risk, is shaped by
his/her knowledge and attitude (Notoatmojdo S., 2010). If there is a normative environment that
supports, and aligns the intention with subjective norms, then the result will be sexual behaviors
where knowledge is consistent with attitude and behavior (Rusmiati D and Hastono P, 2015).

Male adolescents tend to be more sexually-active than female adolescents (Rahyani KY, Utarini A,
Wilopo SA, Hakimi M, 2012). Unhealthy sexual behavior can bring about a number of adverse
effects, one of which is STI, including HIV/AIDS (Kotchick B, Shaffer A, Forehand R, Miller K,

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2001). Aside from physical effect, there may be mental and emotional effect as well. In the long-
term there will also be some economic and social welfare impact that will not just affect the
individual teens, but the family, society and the nation (Rusmiati D and Hastono P, 2015).

6.3.6 Age at First Time Buying Sex

Buying sex is sexual activity followed with providing a reward in the form of money or goods as
payment to a female sex worker (Table 6.10). In this survey the median age of client’s first paid
sex was 22 years. The youngest was 20 years, younger than the aggregate median age, and was
identified among clients in seven Districts/Municipalities. In three cities (North Jakarta City,
Sukabumi City and Bekasi City) the median age clients started buying sex was the same as the age
they started having vaginal sex.

Table 6.10 Age Clients Started Buying Sex

Age at First Sex Age of First Time Buying Sex from FSW in Years
with FSW (%)
District/Municipality n*
Median ≤ 14 15 - 17 18 - 24 ≥ 25

Bukittinggi City# 47 17 8.5 46.8 38.3 6.4

Ogan Komering Ulu (OKU) 268 26 0.0 0.7 31.3 67.9
Pangkal Pinang City 400 23 0.0 7.8 50.0 42.3
Batam City 398 22 0.0 1.8 65.1 33.2
South Jakarta City 190 20 0.0 10.0 66.8 23.2
West Jakarta City 368 25 0.0 5.2 40.2 54.6
North Jakarta City 339 20 0.3 14.7 57.8 27.1
Bekasi 390 21 0.5 11.0 52.3 36.2
Sukabumi City 399 20 0.0 14.5 72.4 13.0
Bekasi City 396 20 0.0 7.3 65.4 27.3
Depok City 398 24 0.0 6.5 49.7 43.7
Pekalongan City 400 27 0.3 4.3 35.5 60.0
Yogyakarta City 397 23 2.5 13.1 41.3 43.1
Sumenep 395 25 0.3 0.0 32.2 67.6
Madiun City 239 20 0.0 10.5 56.9 32.6
Surabaya City 400 21 1.0 14.8 54.3 30.0
Gianyar# 44 19 0.0 20.5 61.4 18.2
Denpasar City 400 23.5 1.3 4.5 48.8 45.5
Kupang City 400 20 0.3 22.5 61.0 16.3
Balikpapan City# 87 21 0.0 10.3 65.5 24.1
Manado City 246 20 3.3 23.6 52.0 21.1
Makassar City 400 20 0.0 8.5 63.8 27.8
Maluku Tenggara Barat 388 22 1.0 5.9 54.1 38.9
Jayapura City 367 21 0.0 1.9 74.4 23.7

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 Age at First Sex Age of First Time Buying Sex from FSW in Years
with FSW (%)
District/Municipality n*
Median ≤ 14 15 - 17 18 - 24 ≥ 25

Aggregate 7578 22 0.5 8.8 53.5 37.2

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of clients
who have had sex with FSWs with missing data taken out

The oldest median age of first paid sex was 27 years in Pekalongan City, which was four years
after clients in Pekalongan City first had vaginal sex (23 years). The survey found that most clients
started buying sex when they became young adults, between 18 to 24 years old (53.5%), and the
same age range was seen in most Districts/Municipalities where this survey was conducted. The
highest was in Jayapura City (74.4%) and the lowest was in Ogan Komering Ulu (OKU) District
(31.3%). These young adult years were also the age when most clients had their first vaginal and
anal sex.

In some Districts/Municipalities, more than half of clients bought sex for the first time in the 18-
to 24-year age range (Table 6.10).

The next largest age group for first paid sex was ≥25 years (37.2%). In four
Districts/Municipalities this age group was actually the highest proportion. Some clients (8.8%)
also started buying sex in their teens (15-17 years), the most was found in Manado City (23.6%)
and the least was in Ogan Komering Ulu (OKU) District (0.7%). From the aggregate data, 0.5%
clients also first bought sex at age ≤14 years and the highest proportion was found in Manado
City (3.3%).

In more than half of Districts/Municipalities, there were clients who started buying sex before
their 14th birthday. This is a high-risk age for STI and HIV/AIDS. The younger an individual starts
buying sex, the longer he/she will be exposed to high-risk behavior, and the greater his/her
likelihood of becoming infected and infecting other people as the number of sex partner also
grows. The longer an individual becomes clients of FSWs the more likely he will be infected with
STI and HIV. It is important to know the age people start buying sex as the longer someone
becomes a client of FSW, the more sex partners he will have, and the higher chance he will be
exposed to HIV/AIDS or STI.

6.4 Other Risk Behavior

Other risk behaviors that were explored in this survey included: history of sex with men, waria
and other women besides with FSWs and their steady partner, also use of injectable drugs.

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 6.4.1 Other Sexual Encounter

Clients were asked about their sexual behavior with other partners, namely other women who
were not FSWs or their steady partner, waria and also men (Table 6.11). Data analysis showed
that almost half (47.7%) of clients also had sex with other women who were not their steady
partner or FSW. The majority was found in Bekasi City (78.0%) and the lowest proportion was in
Makassar City (0.5%). Clients also had sex with waria (2.5%). The highest proportion was in
Bekasi City (6.8%) and Jayapura City (5.7%) while the lowest proportion was in South Jakarta
City (0.4%). Some clients also had sex with men (1.2%) with the largest proportion in Jayapura
City (3.8%).

Table 6.11 Sex with Other Partners and Injecting Drug Use among Client

Other Sexual Encounter (%)

Injecting Drug Use
District/Municipality n
Had sex with other (%)
Had sex with waria Had sex with men
women
Bukittinggi City# 47 44.7 10.6 4.3 0.0
Ogan Komering Ulu (OKU) 336 29.5 0.6 0.3 2.4
Pangkal Pinang City 400 42.8 1.0 0.0 0.3
Batam City 400 45.3 1.0 1.5 14.8
South Jakarta City 227 51.1 0.4 1.3 2.2
West Jakarta City 389 45.8 1.0 1.8 2.1
North Jakarta City 365 68.2 1.9 0.8 2.5
Bekasi 400 78.0 6.8 1.8 2.0
Sukabumi City 400 39.8 1.5 0.5 0.0
Bekasi City 400 64.5 0.5 0.0 1.5
Depok City 400 67.3 0.8 0.3 6.5
Pekalongan City 400 69.3 5.0 3.5 0.8
Yogyakarta City 400 35.5 3.3 1.0 1.8
Sumenep 395 68.1 4.8 1.8 19.5
Madiun City 239 46.4 0.8 0.0 0.8
Surabaya City 400 29.3 5.8 0.3 2.5
Gianyar# 44 72.7 6.8 2.3 2.3
Denpasar City 400 25.5 1.8 0.8 3.3
Kupang City 400 57.3 2.0 0.5 0.8
Balikpapan City# 87 65.5 2.3 2.3 2.3
Manado City 400 43.8 4.8 3.3 1.0
Makassar City 400 5.0 0.8 1.3 0.3
Maluku Tenggara Barat 388 24.0 0.8 0.3 0.0
Jayapura City 367 67.3 5.7 3.8 0.8

Aggregate 7906 47.7 2.5 1.2 3.2

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

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The chance of engaging in risky sexual behavior increases with more types of sex partners. One
form of risky sexual behavior is having multiple partners and multiple types of partner. It
increases the risk for STI and HIV infection and will spread the disease more widely. For some
people, particularly men, having multiple partners is a form of sexual recognition (Paul, McManus,
& Heyes, 2000). It makes men feel superior and they receive recognition from their peers
(Rahardjo, Saputra and Hapsari, 2015).

Self-esteem also plays a role in men’s number of sex partner. An individual with a low self esteem
tends to find ways to make other people view them as valuable, for example by having a lot of sex
partners. Several studies have reported that risky sexual behavior, such as having multiple sex
partner, is linked to a negative self image (Boden & Horwood, 2006). Another common practice
that relates to multiple sex partner is sexting. Sexting tends to be done by someone who considers
sex as something fun and satisfactory (Ferguson, 2011).

6.4.2 Injecting Drug Use

Table 6.11 describes the analysis on clients’ use of injectable drugs. As an aggregate, 3.2% of
clients had injected drugs. The highest proportion was in Sumenep District (19.5%) and the
lowest was in Maluku Tenggara Barat District (0.0%). Sexual behavior of injecting drug users had
been thought to be the cause of HIV transmission from PWID to the general population (Besral,
Utomo B & Zani AP, 2004). A study by Felton Besral, Utomo B and Zani AP (2004) reported that
drug users who often shared needles also frequently engaged in unprotected sex with multiple
sex partners. In Ireland it is reported that more than 50% of PWID never used condom during sex
with their steady partner and 32.6% never used condom during sex with a non-steady partner.
None of those partners were PWID (Besral, Utomo B & Zani AP, 2004).

Calculation to predict the number of HIV cases that can occur among PWID noted that the
potential for HIV transmission from PWID to his/her partner was significantly large. The
potential will be even larger when an individual’s sexual network included commercial sex
partner, creating a bridge for HIV transmission to the general population. Maximum effort would
be necessary to cut the chain of transmission by education about HIV transmission, promotion of
consistent condom use during sex (Besral, Utomo B & Zani AP, 2004). Reducing infection among
PWID will reduce the infection among the general population who are not PWID (ECDC &
EMCDDA, 2011). Injecting drug use is a risk behavior for Hepatitis C infection and co-infection (Ii,
Larre Keen et al., 2015).

Sexual transmisson of HIV can be prevented through 6 ways, i.e. a). abstinence for those who are
not yet married; b). being faithful to a steady HIV-negative partner; c). consistent condom use; d).
saying no to drugs/addictive substance; e). education and early treatment of STI to improve the
ability to prevent transmission; and f). other prevention method through circumcision (MOH RI,
2013).

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6.6 Sexually-Transmitted Infection (STI)
Sexually-transmitted infection (STI) is infection that is caused by various microbes/bacteria,
virus, parasite and genital lice that are mostly transmitted through sex. Not all STIs present any
symptom, and when symptoms are present, they do not necessarily appear on the genital (MOH
RI, 2017). More than 30 different types of pathogen can be transmitted through sex with clinical
manifestations that vary by sex/gender and age.

Sexually-transmitted infections (STIs) are primarily transmitted through sex. Infection however
can also occur from a pregnant woman to her baby in the womb, or during childbirth through
exchange of contaminated blood product or tissue. Sometimes, medical devices can also be the
vehicle of transmission (MOH RI, 2016). The 2018-2019 IBBS explored the STI situation in the
client group. Information presented in this section included details about STI test, receipt of STI
test result and STI treatment by a health provider.

6.6.1 STI Testing and Treatment

Among all the clients, only 6.4% had been tested for STI (Table 6.12). The highest proportion of
test was in Bekasi City (17.0%) and the lowest was in Pangkal Pinang City (0.3%). Most clients
who had STI test also received the test result, and in some Districts/Municipalities, 100% of
clients who were tested received the result. However, in Sukabumi City, less than half (48.3%) of
clients found out the result of their STI test.

Table 6.12 STI Testing among Clients, Treatment and Treatment Location

Know the STI Test Has Consulted a Health

Has Had STI Test
District/Municipality n Result Provider
(%)
(%)* (%)*

Bukittinggi City# 47 0.0 0.0 0.0

Ogan Komering Ulu (OKU) 336 0.6 100.0 0.0

Pangkal Pinang City 400 0.3 100.0 0.0

Batam City 400 5.0 60.0 0.0

South Jakarta City 227 9.3 85.7 38.1

West Jakarta City 389 4.1 100.0 37.5

North Jakarta City 365 12.6 91.3 26.1

Bekasi 400 5.0 95.0 30.0

Sukabumi City 400 7.3 48.3 6.9

Bekasi City 400 17.0 100.0 33.8

Depok City 400 5.5 100.0 72.7

Pekalongan City 400 1.0 75.0 0.0

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 Know the STI Test Has Consulted a Health
Has Had STI Test
District/Municipality n Result Provider
(%)
(%)* (%)*

Yogyakarta City 400 10.8 86.0 60.5

Sumenep 395 6.6 92.3 50.0

Madiun City 239 2.9 100.0 57.1

Surabaya City 400 8.5 91.2 50.0

Gianyar# 44 9.1 25.0 25.0

Denpasar City 400 8.3 100.0 54.5

Kupang City 400 9.3 100.0 56.8

Balikpapan City# 87 2.3 100.0 50.0

Manado City 400 10.5 88.1 33.3

Makassar City 400 3.8 93.3 26.7

Maluku Tenggara Barat 388 1.8 100.0 14.3

Jayapura City 367 4.1 93.3 26.7

Aggregate 7906 6.4 9.2 38.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among clients
who have had STI test; **Among clients with positive STI test

6.6.2 STI Treatment

A third of clients (38.4%) who had STI test also sought treatment from a health provider (went to
puskesmas/hospital/private doctor’s practice). In several Districts/Municipalities, more than
50% of clients had visited a health provider for STI service. Preventing and treating STI is known
to reduce the risk for sexual transmission of HIV, particularly among people with multiple sex
partners like sex workers and their clients. Inflammation and ulceration caused by STI will enable
the HIV virus from a HIV-positive person to enter the uninfected partner more easily during
unprotected sex. For each unprotected sex with an individual who has genital ulcer, the risk for
HIV infection is estimated to increase by 50-300 times. (MOH, 2016).

6.7 Human Immunodeficiency Virus (HIV)

HIV (human immunodeficiency virus) is a virus that attacks the human immune system by
infecting and destroying the CD4 cells. As a result, the body can no longer protect itself from
various illnesses (opportunistic infections). The more CD4 cells are destroyed, the weaker the
person’s immune system will be, and the more vulnerable the person becomes toward various
diseases (MOH RI, 2017). The 2018-2019 IBBS explored HIV-related information among clients
starting from testing to treatment.

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6.7.1 HIV Status

The majority of clients (86.3%) never had an HIV test (Table 6.13). Only 7.8% of clients took the
initiative to get tested. This showed that the level of awareness about HIV risk among client was
still low, which was probably due to the low level of knowledge on HIV (48.2%). Level of
comprehensive knowledge on HIV was only 16.1%. Findings indicated that clients with higher
level of education tend to have more knowledge about HIV, and were more motivated to initiate
testing (11.4% for clients with university-level education). The highest proportion of clients who
never had HIV test was in Sumenep District (98.2%) and the lowest was in Batam City (30.5%).

6.7.2 HIV Test

Guideline for HIV counseling and testing is a mandatory reference for health providers, program
managers, professional HIV counselors, workplace managers and other stakeholders who
provide HIV counseling and testing. Counseling and testing are necessary for HIV diagnosis to
prevent transmission, reduce prevalence of HIV and provide early treatment (MOH RI, 2014).

Table 6.13 Last HIV Test among Clients

HIV Test (%)

District/Municipality n Based on On Own Initiative and
On Own Initiative Based on Referral Never
Referral
Bukittinggi City# 47 10.6 4.3 0.0 85.1
Ogan Komering Ulu (OKU) 336 2.1 0.3 0.0 97.6
Pangkal Pinang City 400 1.5 0.3 1.0 97.3
Batam City 400 12.0 2.3 24.3 61.5
South Jakarta City 227 7.9 0.9 2.2 89.0
West Jakarta City 389 5.1 2.1 1.8 91.0
North Jakarta City 365 18.9 1.4 4.9 74.8
Bekasi 400 13.3 1.8 2.3 82.8
Sukabumi City 400 7.0 4.5 2.8 85.8
Bekasi City 400 7.8 2.0 5.5 84.8
Depok City 400 0.8 1.5 2.8 95.0
Pekalongan City 400 4.5 1.0 5.3 89.3
Yogyakarta City 400 11.3 2.8 7.0 79.0
Sumenep 395 1.0 0.0 0.8 98.2
Madiun City 239 0.8 1.7 5.9 91.6
Surabaya City 400 9.0 1.0 8.5 81.5
Gianyar# 44 20.5 9.1 11.4 59.1
Denpasar City 400 6.0 2.0 1.3 90.8
Kupang City 400 6.5 3.3 1.8 88.5
Balikpapan City# 87 33.3 2.3 16.1 48.3

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 HIV Test (%)
District/Municipality n Based on On Own Initiative and
On Own Initiative Based on Referral Never
Referral
Manado City 400 17.5 1.5 3.3 77.8
Makassar City 400 10.0 1.8 0.8 87.5
Maluku Tenggara Barat 388 7.2 2.3 1.5 88.9
Jayapura City 367 8.4 3.3 3.3 85.0

Aggregate 7906 7.7 4.8 1.2 86.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Regulation of the Minister of Health Republic of Indonesia Number 21/2013 on HIV and AIDS
Intervention states that HIV and STI test should be repeated every 6 months (MOH RI, 2013).
Among the clients, 74.8% who were tested for HIV also received their test result. That meant
25.2% of clients who were tested did not know their HIV test result (Table 6.14). HIV testing
among clients is influenced by several factors. Some men consider HIV testing shameful as it is
tied to their masculinity (Paul J. Fleminga, et al., 2017). The low coverage of HIV test among FSW’s
clients showed that this group would benefit from preventive interventions (Paul J. Fleminga, et
al., 2017).

Indonesia has started implementing HIV counseling and testing since 2004 through a client-
initiated approach known as voluntary counseling and testing (VCT). Currently, VCT is still
implemented for clients who would like to know their HIV status. In 2010, an approach known as
provider-initiated testing and counseling (PITC) was launched, which together with VCT is
implemented with the goal to provide universal access to testing, reduce stigma and
discrimination and reduce missed opportunities for preventing HIV (MOH RI, 2014).

6.7.3 HIV Treatment

Adherence to ARV therapy will have a positive impact on the health status of the person who live
with HIV/AIDS (PLHIV), well as the surrounding community. ART improves PLHIV’s quality of
life and reduce HIV transmission. As more PLHIV enroll in treatment, the impact on the individual
and community will be larger, and will accelerate the progress toward “3 zeroes”, i.e. zero new
infection, zero AIDS-related death, zero stigma and discrimination (MOH RI, 2013). This section
presents information regarding HIV service that clients received, which included CST service,
ARV treatment in the past, ARV treatment up to now, dropping out of treatment for more than
three months, viral load test in the last 12 months and receipt of viral load test result (Table 6.14).

Indonesia and a number of countries are committed to implement the 90-90-90 Fast-Track
approach, which calls for detecting 90% of people who are infected with HIV, providing early ARV
therapy to 90% of PLHIV who have been detected, and achieving viral load suppression in 90%
of PLHIV who are on ART. This Fast-Track approach is expected to reduce the number of new HIV

178
 infections to meet the Sustainable Development Goals (SDGs) target (MOH RI, 2019). Analysis
however revealed that currently only 83.3% of clients have enrolled into ART. More efforts would
be needed to achieve the 90-90-90 Fast-Track target.

Table 6.14 HIV Testing and Treatment among Clients

Stopped
Receive Viral Know the
Receive CST taking Viral
Receive Test Receive ARV ARV until Load Test viral load
District/Municipality n* Service ARV for more Load Test
Result (%) (%)2 now in the last test result
(%)1 than 3 months (%)3
(%)3 12 months (%)5
(%)4

Bukittinggi City# 7 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Ogan Komering Ulu (OKU) 8 12.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Pangkal Pinang City 11 54.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Batam City 154 90.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0
South Jakarta City 25 80.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
West Jakarta City 35 94.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0
North Jakarta City 92 82.6 100.0 100.0 100.0 0.0 100.0 100.0 100.0
Bekasi 69 52.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Sukabumi City 57 47.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Bekasi City 61 95.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Depok City 20 95.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Pekalongan City 43 69.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Yogyakarta City 84 29.8 100.0 50.0 100.0 100.0 100.0 0.0 100.0
Sumenep 7 57.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Madiun City 20 95.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Surabaya City 74 86.5 100.0 100.0 100.0 100.0 0.0 0.0 0.0
Gianyar# 18 61.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Denpasar City 37 83.8 100.0 100.0 100.0 0.0 0.0 0.0 0.0
Kupang City 46 69.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Balikpapan City# 45 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Manado City 89 71.9 100.0 100.0 100.0 100.0 100.0 0.0 100.0
Makassar City 50 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Maluku Tenggara Barat 43 62.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Jayapura City 55 85.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Aggregate 1080 74.8 75.0 83.3 100.0 60.0 60.0 33.3 100.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of clients
who had HIV test; 1Among HIV-positive clients based on interview results; 2Among client who receive CST service; 3Among clients
who receive ARV; 4Among clients who are still taking ARV until now; 5Among clients who had viral load test

Based on the interview results, quite a large proportion of clients who were identified as HIV
positive received CST service (75.0%), and from those, a majority also received ARV (83.3%).
That meant there was 16.7% of clients who were lost, or 16.7% of missed opportunities to give
ARV treatment. All of the clients who received ARV are still taking ARV currently (100%), though

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in the past 60% of them did stop taking ARV for more than three months. Among clients who are
on ART, 60.0% received viral load test (Table 6.14), and 33.3% of them had the viral load test in
the last 12 months. All the clients received their viral load test result (100.0%).

Increased coverage of HIV testing has to be accompanied with increased access to follow-on
service, one of which is ARV therapy. Aside from fulfilling a treatment function, ARV therapy also
serves a preventive function as part of treatment as prevention (TasP) strategy. Every ARV
therapy referral hospital at the Provincial and District/Municipality level has to be able to
guarantee that PLHIV will have access to ARV therapy. Primary health facility can perform early
detection of HIV and gradually also start initiating ARV therapy (MOH RI, 2014). Currently, ARV
therapy is the most effective prevention for HIV transmission.

An HIV-positive individual with an HIV-negative partner (serodiscordant couple) has to be

informed that one objective of ARV therapy is to reduce the risk of transmission to the HIV-
negative partner (Ying Qing Chena, et al., 2008). For PLHIV with CD4 count <350 cells/mm3, or
have active pulmonary TB, or have Hepatitis B, or are currently pregnant or breastfeeding, or will
be starting ARV therapy, information that is provided should emphasize the aspect of prevention
so that adherence to ARV therapy can improve. A PLHIV with a serodiscordant partner and CD4
count >350 cells/mm3 without any other contraindications should be offered to immediately
initiate ARV therapy with the objective to reduce the risk of transmission to his/her partner. The
use of antiretroviral for prevention is part of Treatment as Prevention (TasP) activity that in
Indonesia is known as SUFA (Strategic Use of Antiretrovirals). It is critical to realize that reduced
number of viral particles as a result of ARV has to be accompanied with decreased risk behavior,
consistent and appropriate use of ARV, consistent condom use, safe sex and safe drug use
practices, consistent STI treatment at the appropriate regimen. They are imperative to prevent
HIV transmission. This effort is known as positive prevention (MOH RI, 2014).

Considering the high risk of HIV transmission, case management will have to focus not just on the
medical side, but also the psychosocial aspect of HIV intervention, while primary, secondary and
tertiary prevention should be performed through a community-based approach. One prevention
effort would be to provide early detection so people can find out their HIV status through
voluntary, not forced or mandated, counseling and testing for HIV/AIDS (Nasrodin, 2007).
Knowing one’s HIV status early will facilitate higher uptake of prevention, support and treatment
service. Voluntary counseling and testing of HIV will be one prevention strategy that provides an
entrance to all services, information, education, therapy, and psychosocial support. By opening
access widely, the need for accurate and timely information can be met such that the thinking
process, feeling and behavior can be directed toward healthier behavior. Components of VCT are
pre-test counseling, HIV testing, post-test counseling (MOH, 2006, 2008).

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6.8 Tuberculosis (TB)
Tuberculosis, commonly abbreviated as TB, is a communicable disease that is caused by
Mycobacterium tuberculosis, that attacks the lungs and other organs. Tuberculosis (TB) was one
outcome that was assessed in the 2018-2019 IBBS. Information on TB that is presented here
included TB symptoms that clients experienced in the last year, TB testing, receipt of TB test
result, TB treatment and HIV test (Table 6.15).

Overall, 4.6% of clients has had a TB test (Table 6.15), and the majority of them (88.4%) received
the test result. Less than a quarter however (21.2%) received treatment. This may be because the
remaining 78.8% had a negative test result and therefore did not need treatment. Low rate of TB
test among clients was partly influenced by low level of knowledge and awareness about TB.
Previous studies had reported that TB knowledge was influenced by education, income, age,
marital status and sex transaction venue (Rana et al., 2019). TB screening in health facilities is a
cost-efficient strategy to increase detection of TB (Silvia S, et al., 2015).

HIV infection is one risk factor for TB. In general, 10% of individuals who are infected with TB
will suffer from TB, but with HIV-positive individuals, the incidence of TB will increase. People
who are HIV positive have a risk of getting TB that is 20-37 times higher than HIV-negative
individuals. This will cause TB to spread in the community as well. Without treatment, TB will be
fatal to half of TB patients and the risk increases among HIV-positive patients who suffer from
TB. As much as 25% of deaths among PLHIV are caused by TB (MOH RI, 2016).

To improve clients’ knowledge and awareness about TB, health promotion efforts and
information dissemination is necessary. The Regulation of the Minister of Health Republic of
Indonesia Number 67/2016 on Tuberculosis Control states that health promotion activities to
control TB should be directed to provide correct and comprehensive knowledge about prevention
of transmission, treatment, and healthy and clean lifestyle (PHBS). The objective would be to
change the behavior and attitude of target groups, also eliminate stigma and discrimination from
the society, and health providers toward TB patients (MOH RI, 2016). The survey was not able to
find out whether clients who tested positive for TB were offered HIV test. Based on the Regulation
of the Minister of Health Number 21/2013 on HIV Counseling and Testing, Indonesia has started
the implementation of provider-initiated testing and counseling (PITC) which actually requires
every TB patient to also be tested for HIV (MOH RI, 2013).

6.9 Hepatitis
Hepatitis is an inflammation of the liver, a communicable disease that is transmitted by a virus.
Viruses that can cause hepatitis consist of several types: Hepatitis A, B, C, D and E. The 2018-2019
IBBS collected information about Hepatitis B and C.

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 6.9.1 Hepatitis B

Viral Hepatitis B, called simply as Hepatitis B is a communicable inflammation of the liver caused
by the Hepatitis B virus (MOH RI, 2015). Among the clients in this survey, only 1.8% had ever
been tested for Hepatitis B (Table 6.15). The majority was in Surabaya City (6.0%) and the lowest
proportion was in Pangkal Pinang City, West Jakarta City, Bekasi District, Pekalongan City and
Jayapura City (0.3%). It was observed that the lowest proportion of Hepatitis B test was in the
urban areas. Most of clients who received Hepatitis B test also received the test result (92.3%),
and the same was true in most Districts/Municipalities the survey looked at, except in Madiun
City where only 25.0% clients who were tested received their test result.

6.9.2 Hepatitis C

The proportion of clients who had Hepatitis C test was only half of the proportion who had
Hepatitis B test (0.8%). The most was among clients in Surabaya City (3.8%), similar to the
situation seen in Hepatitis B test. In some Districts/Municipalities, no clients had Hepatitis C test
(Table 6.15). While most clients who had both Hepatitis B and C test were found in Surabaya City,
the lowest proportion of clients with both tests was found in West Jakarta. The majority of clients
who were tested received their test result (92.3%) and most of those who tested positive also
received Hepatitis C treatment.

Table 6.15 TB, Hepatitis B and C Test, Result and Treatment among Clients

TB (%) Hepatitis B (%) Hepatitis C (%)

Receive
District/Municipality n Receive TB Know the Know the
Know the TB Hep B Hep C Hep C
TB Test Treatment Hep B Test Hep C Test
Test Result* Test Test Treatment
Package* Result** Result***
****
Bukittinggi City# 47 0.0 0.0 0.0 4.3 100.0 0.0 0.0 0.0
Ogan Komering Ulu (OKU) 336 1.8 66.7 33.3 2.7 100.0 0.0 0.0 0.0
Pangkal Pinang City 400 0.8 66.7 0.0 0.3 100.0 0.3 0.0 0.0
Batam City 400 5.8 91.3 4.3 0.8 66.7 0.0 0.0 0.0
South Jakarta City 227 4.8 90.9 27.3 1.3 100.0 0.9 100.0 100.0
West Jakarta City 389 1.5 66.7 0.0 0.3 100.0 0.0 0.0 0.0
North Jakarta City 365 4.9 83.3 22.2 2.2 87.5 0.5 100.0 0.0
Bekasi 400 3.3 100.0 30.8 0.3 100.0 0.3 0.0 0.0
Sukabumi City 400 4.8 73.7 5.3 1.8 71.4 0.3 100.0 0.0
Bekasi City 400 5.0 100.0 5.0 2.5 100.0 0.8 100.0 0.0
Depok City 400 7.0 92.9 60.7 3.0 100.0 1.8 100.0 100.0
Pekalongan City 400 2.3 88.9 11.1 0.3 100.0 0.0 0.0 0.0
Yogyakarta City 400 7.3 65.5 6.9 2.5 100.0 1.3 80.0 100.0
Sumenep 395 8.1 87.5 34.4 0.8 100.0 0.0 0.0 0.0

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 TB (%) Hepatitis B (%) Hepatitis C (%)
Receive
District/Municipality n Receive TB Know the Know the
Know the TB Hep B Hep C Hep C
TB Test Treatment Hep B Test Hep C Test
Test Result* Test Test Treatment
Package* Result** Result***
****
Madiun City 239 3.3 100.0 25.0 1.7 25.0 0.8 100.0 100.0
Surabaya City 400 9.0 94.4 27.8 6.0 91.7 3.8 100.0 100.0
Gianyar# 44 4.5 100.0 50.0 2.3 100.0 2.3 100.0 0.0
Denpasar City 400 2.8 81.8 9.1 1.5 100.0 0.8 100.0 100.0
Kupang City 400 3.3 100.0 30.8 1.0 100.0 0.2 100.0 0.0
Balikpapan City# 87 5.7 100.0 40.0 1.1 100.0 0.0 0.0 0.0
Manado City 400 10.0 87.5 15.0 3.0 91.7 3.0 91.7 80.0
Makassar City 400 3.3 100.0 30.8 0.8 100.0 0.3 100.0 0.0
Maluku Tenggara Barat 388 3.4 100.0 7.7 1.8 100.0 1.3 100.0 0.0
Jayapura City 367 3.5 92.3 0.0 0.3 100.0 0.3 0.0 0.0

Aggregate 7906 4.6 88.2 21.2 1.6 92.3 0.8 92.0 92.9
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples ; *Among clients
who had TB test; **Among client who had Hepatitis B test;***Among client who had Hepatitis C test; ****Among clients who stated
their Hepatitis C test result was positive.

6.10 Positivity Rate

This section presents the positivity rate of the biological tests performed on the client group,
which included tests for HIV, Syphilis, Hepatitis B and C. In total 5760 samples were collected
from 24 Districts/Municipalities and tested for HIV, and 5772 samples were tested for syphilis.
For Hepatitis B and C 1600 samples were collected from four Districts/Municipalities and tested.
Testing results are presented as an aggregate of results from 21 Districts/Municipalities that had
large enough samples (HIV and Syphilis). Three Districts/Municipalities with small number of
samples were not included in the aggregate analysis, namely Bukittinggi City (0 samples for HIV
and Syphilis), Gianyar District (45 samples for HIV) and Balikpapan City (91 samples for HIV and
Syphilis). Hepatitis B and C test was performed only in four Districts/Municipalities of West Java
Province: Bekasi District, Sukabumi City, Bekasi City and Depok City. In addition to presentation
of results as an aggregate, results for each District/Municipality are also presented, including
Districts/Municipalities with small number of samples.

6.10.1 Positivity Rate as an Aggregate

As an aggregate, 8013 samples were collected from 21 Districts/Municipalities and tested for HIV,
while for syphilis 7613 samples were collected and tested. Reactive result on an anti-HIV test was
categorized as HIV positive, while positive syphilis test consisted of three types: reactive, early-
stage syphilis and late-stage syphilis. The three categories reflected the level of infection and
determined the type of treatment that should be provided. In the 2018-2019 IBBS syphilis test

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results had five categories: non-reactive, false positive syphilis, early-stage syphilis, late-stage
syphilis and reactive. These five categories were then streamlined into three: syphilis, false
positive syphilis, and non-reactive. A positive result meant the individual had syphilis without
further categorizing the stage of infection. A non-reactive result meant the individual did not have
syphilis, while a false positive result meant the result was inconsistent, reactive on the rapid test
and non-reactive on the titer test. A total of 1600 samples from four selected
Districts/Municipalities were tested for each Hepatitis B and C.

The result as an aggregate is presented in Figure 6.1. The positivity rate of HIV among clients was
1.1% at 95% CI (0.02 – 1.4). The positivity rate of Syphilis was 2.0% at 95% CI (1.2 – 2.4). The
positivity rate of Hepatitis B was 1.8% at 95% CI (1.3 – 2.6) and the positivity rate of Hepatitis C
was 0.5% at 95% CI (0.3 – 1.0). The positivity rate of HIV, Syphilis and Hepatitis that are chronic
diseases was quite low. This indicated that in addition to treatment, interventions to prevent
infection would also be important to reduce the number of new cases.
2.5
2
95% CI (1,2 – 2,4) 1.8
2
95% CI (1,3 – 2,6)

1.5 1.1
95% CI ( 0,02 – 1,4)

1
0.5
95% CI (0,3 – 1,0)
0.5

0
N= 8013 N=7613 N=1600 N=1600
HIV* Syphilis Hepatitis B Hepatitis C
*
Figure 6.1 Positivity Rate of HIV, STI and Hepatitis B and C Aggregate Data in Clients
*Without Districts/Municipalities that had a small number of samples i.e. Bukittinggi City, Gianyar District and
Balikpapan City

6.10.2 Positivity Rate Per District/Municipality

A look at the positivity rate in each District/Municipality revealed that nine

Districts/Municipalities had an HIV positivity rate above the aggregate positivity rate. They were
South Jakarta City (2.6%), Bekasi District (1.4%), Pekalongan City (1.8%), Yogyakarta City
(2.0%), Surabaya City (2.0%), Denpasar City (2.3%), Makassar City (3.8%) and Jayapura City
(1.5%). Makassar City had the highest HIV positivity rate (3.8%) while Ogan Komering Ulu (OKU)
District, Manado City and Maluku Tenggara Barat District had the lowest positivity rate (0.0% or
no HIV cases among clients) (Table 6.16). The highest positivity rate of syphilis was found in
Maluku Tenggara Barat District (6.0%) and the lowest was in Ogan Komering Ulu (OKU) District
and Bekasi City (0.0%).

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 It was observed that Maluku Tenggara Barat District had the lowest proportion of HIV (0.0%) but
the highest proportion of Syphilis. The positivity rate of Hepatitis B in the four
Districts/Municipalities varied from 1.5% to 2.0%. The highest was in Bekasi District and the
lowest in Sukabumi City and Depok City. The positivity rate of Hepatitis C was 0.3% in Bekasi City
and Sukabumi City, 0.8% in Bekasi District and Depok City.

Table 6.16 Positivity Rate of HIV, Syphilis, Hepatitis B and C among Clients per District/Municipality

Hepatitis
District/Municipality n HIV n Syphilis n
Hepatitis B Hepatitis C
Bukittinggi City 0 0.0 47 0.0

Ogan Komering Ulu (OKU) 381 0.0 381 0.0

Pangkal Pinang City 400 0.5 400 1.6

Batam City 400 0.8 400 0.3

South Jakarta City 230 2.6 230 3.3

West Jakarta City 400 1.0 400 1.3

North Jakarta City 365 0.5 365 0.8

Bekasi 400 1.3 400 0.5 400 2.3 0.8

Sukabumi City 400 0.8 400 2.5 400 2.0 0.3

Bekasi City 400 0.5 400 0.0 400 1.5 0.3

Depok City 400 1.0 400 1.0 400 1.5 0.8

Pekalongan City 400 1.8 400 2.0

Yogyakarta City 400 2.0 400 1.0

Sumenep 400 0.5 400 0.3

Madiun City 239 0.4 239 1.8

Surabaya City 400 2.0 400 1.7

Gianyar 45 0.0 45 2.3

Denpasar City 400 2.3 0 4.4

Kupang City 400 1.0 400 6.3

Balikpapan City 91 3.3 91 1.1

Manado City 399 0.0 399 1.0

Makassar City 400 3.8 400 1.3

Maluku Tenggara Barat 399 0.0 399 9.0

Jayapura City 400 1.5 400 2.5

Note:
Hepatitis B and C test was not done in these sites

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 PWID
People who Inject Drugs (PWID) are one at-risk group who were the target population of 2018-
2019 IBBS. Based on sample size calculation, it was planned to recruit 220 PWID respondents
from each of 18 selected Districts/Municipalities, to arrive at a total of 3960 respondents. In the
implementation, the target number of respondents was not achieved, and only 2390 respondents
(59.59%) were interviewed.

Table 7. 1 Data Collection Coverage among PWID

Target Behavioral Data Biological Data

No Province District/Municipality
Samples Coverage % Coverage %
1 Aceh Banda Aceh City 220 15 6.8 20 9.1

2 West Sumatra Padang City 220 76 34.5 78 35.5

3 Lampung Bandar Lampung City 220 57 25.9 57 25.9

4 DKI Jakarta East Jakarta City 220 180 81.8 183 83.2

5 Bogor 220 219 99.5 220 100.0

6 Sukabumi 220 220 100.0 220 100.0

7 West Bandung 220 220 100.0 220 100.0

8 West Java Sukabumi City 220 214 97.3 219 99.5

9 Bandung City 220 219 99.5 220 100.0

10 Bekasi City 220 215 97.7 220 100.0

11 Depok City 220 218 99.1 220 100.0

12 Central Java Salatiga City 220 104 47.3 104 47.3

13 DI Yogyakarta Yogyakarta city 220 16 7.3 16 7.3

14 Tangerang City 220 36 16.4 40 18.2

Banten
15 South Tangerang City 220 43 19.5 41 18.6

16 Bali Badung 220 84 38.2 84 38.2

17 NTT Kupang City 220 4 1.8 4 1.8

18 South Sulawesi Makassar City 220 220 100.0 220 100.0

3960 2360 59.6 2386 60.3

In this survey, the level of participation among PWID was only 59.59% and data collection
coverage in each District/Municipality varied significantly from 1.82% - 100%. In Kupang City,
from the planned 220 respondents, only 4 PWID were recruited (1.82%), which matched the
PWID mapping data in Kupang City. In contrast, 100% of the targeted respondents was able to be
recruited in three Districts/Municipalities, i.e. in Sukabumi District, West Bandung District and
Makassar City. West Java had a very good response rate (> 97% in seven Districts/Municipalities).
The 2016 PWID population estimate did list West Java as having the highest number of PWID, so
it was as expected that a lot of PWID could be recruited and interviewed.

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 In the above table the number of biological data was larger than the number of behavioral data.
As many as 29 biological samples did not have behavioral data, while 3 behavioral questionnaires
did not have the biological data component. One reason for this was because the software for
behavioral data collection was not yet updated causing the data to be unreadable as it reached
the central team. This happened in Banda Aceh City.

In some Districts/Municipalities that had a very low data coverage, the data was considered
unable to be representative of the respective District/Municipality and was therefore excluded
from the aggregate data analysis. These included the following Districts/Municipalities:

Table 7. 2 Districts/Municipalities that were Excluded from the Aggregate Data Analysis
Behavioral Data
No Province District/Municipality
Coverage %
1 Aceh Banda Aceh City 15 6.8
2 West Sumatra Padang City 76 34.5
3 Lampung Bandar Lampung City 57 25.9
4 DI Yogyakarta Yogyakarta City 16 7.3
5 Tangerang City 36 16.4
Banten
6 South Tangerang City 43 19.5
7 Bali Badung 84 38.2
8 NTT Kupang City 4 1.8

Samples from the eight Districts/Municipalities that were excluded were 331 or around 14.0% of
the total collected samples.

7.1 Respondent Characteristics

This section presents data from the behavioral questionnaire that was administered to the PWID
group. In total 2360 respondents from the 18 Districts/Municipalities completed the
questionnaire. The characteristics presented in this section included age, sex/gender, highest
educational level, marital status, permanent residence, living arrangement, main occupation and
health insurance coverage.

Table 7. 3 Characteristics of PWID

Age Group Sex/Gender Educational Level

District / Median Never Jr.High High
n 15-19 20-24 25-49 ≥50 Elem.Sch College/
Municipality Age Male Female went to Sch/ Sch./
years years years years / Equiv. Univ
school Equiv. Equiv.
Banda Aceh
15 27 6.7 26.7 66.7 0.0 100.0 0.0 0.0 0.0 6.7 46.7 46.7
City#

Padang City# 76 25.5 31.6 13.2 55.3 0.0 98.7 1.3 0.0 9.2 32.9 55.3 2.6

Bandar
57 35 5.3 22.8 71.9 0.0 75.4 24.6 0.0 5.3 12.3 56.1 26.3
Lampung City

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 Age Group Sex/Gender Educational Level
District / Median Never Jr.High High
n 15-19 20-24 25-49 ≥50 Elem.Sch College/
Municipality Age Male Female went to Sch/ Sch./
years years years years / Equiv. Univ
school Equiv. Equiv.
2.8 2.8 93.9 0.6 80.6 19.4 0.0 2.8 13.3 62.8 21.1

Bogor 219 36 0.0 6.8 91.8 1.4 98.2 1.8 0.9 1.8 10.5 70.3 16.4

Sukabumi 220 31 1.4 15.0 82.7 0.9 97.3 2.7 0.5 15.5 39.1 42.3 2.7

West Bandung 220 32 5.0 7.3 87.7 0.0 99.1 0.9 0.0 0.5 19.1 67.7 12.7

Sukabumi City 214 33 7.0 14.0 77.1 1.9 96.7 3.3 0.0 4.2 17.3 69.2 9.3

Bandung City 219 22 27.4 43.8 28.8 0.0 94.5 5.5 0.0 16.4 41.6 38.4 3.7

Bekasi City 215 31 3.7 15.8 79.1 1.4 98.1 1.9 1.4 0.5 3.3 83.3 11.6

Depok City 218 32 6.4 13.3 73.4 6.9 78.0 22.0 0.9 13.3 20.6 52.8 12.4

Salatiga City 104 26 6.7 35.6 55.8 1.9 95.2 4.8 1.0 16.3 32.7 45.2 4.8

Yogyakarta
16 33.5 0.0 6.3 93.8 0.0 93.8 6.3 0.0 6.3 18.8 68.8 6.3
City#
Tangerang
36 37 0.0 16.7 83.3 0.0 100.0 0.0 0.0 0.0 8.3 80.6 11.1
City#
South
Tangerang 43 25 14.0 34.9 51.2 0.0 93.0 7.0 4.7 7.0 20.9 51.2 16.3
City#

Badung# 84 36.5 0.0 7.1 89.3 3.6 94.0 6.0 0.0 17.9 20.2 54.8 7.1

Kupang City# 4 36 0.0 0.0 100.0 0.0 100.0 0.0 0.0 0.0 0.0 50.0 50.0

Makassar City 220 24 19.5 34.1 46.4 0.0 92.3 7.7 0.9 8.2 14.5 57.7 18.6

Aggregate 2029 32 8.2 18.2 72.1 1.5 93.1 6.9 0.5 7.6 20.7 59.6 11.5

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The majority of PWID were adults between the age of 25 to 49 years (72.1%). Age can be used as
a proxy of how long an invidual has been injecting drugs. The 2015 National Household Survey
on Drug Abuse in 20 Provinces reported that the average age people started using drugs was 19
(National Narcotics Agency / BNN, 2015). If a lot of PWID were older than 30 years that meant
more respondents were “old-timer PWID”. A cross-tabulation between respondent’s age and
length of time they have been injecting drugs showed that 64.2% of PWID aged 25-49 years old
had been injecting drugs for more than 5 years. The younger the age, the shorter time they have
been injecting drugs. In the 15- to 19-year age group, only 3.0% had been injecting drugs for more
than 5 years. In the older group between 20 to 24 years, 20.8% had become PWID for more than
5 years.

Almost all PWID interviewed were male (93.06%), and only 6.94% were female. This was twice
as high as the result of a meta analysis that estimated the percentage of female PWID in South
East Asia to be 3.1% (2.1% - 4.1%) (Degenhardt et al., 2017). Literatures report that women
usually become PWID because their male partner encouraged them. The male partner typically
helped women with their first injection, shared injection equipment, and women then injected

188
 drugs after the male partner. This meant women are vulnerable to infections that are transmitted
through blood, like HIV (Meyers et al., 2018). In this survey, the percentage of HIV positive among
female PWID (17.18%) was slightly higher than that among male PWID (14.51%) (attachment 9).

In terms of education, the majority of PWID completed high school/equivalent (59.32%),

followed by those who completed junior high school/equivalent (20.59%) and university/college
(11.78%). This result was similar to the finding in the 2015 IBBS, and the 2015 National
Household Survey on Drug Abuse in 20 Provinces (BNN, 2015). Educational level is known to
correlate with level of comprehensive knowledge about HIV. Respondents with higher education
(university degree) had more comprehensive knowledge (81.6%) compared to respondents who
completed high school (60.8% had comprehensive knowledge on HIV). The Protection Motivation
Theory says that people with higher level of education would have a higher risk perception,
causing them to be more aware about the negative impact that may be brought about by risk
behaviors.

Table 7. 4 Marital Status and Living Arrangement of PWID

Marital Status (%) Living Arrangement (%)
District /
n n With Friends/ With PWID With Female With Male
Municipality Married Unmarried Divorced Alone Other
Family Steady Partner Sex Partner Sex Partner
Banda Aceh City# 15 80.0 20.0 0.0 11 0.0 81.8 0.0 18.2 0.0 0.0
Padang City# 76 69.7 27.6 2.6 73 1.4 72.6 0.0 26.0 0.0 0.0
Bandar Lampung
57 40.4 42.1 17.5 57 10.5 57.9 7.0 22.8 1.8 0.0
City#
East Jakarta City 180 31.1 53.9 15.0 178 7.9 53.4 5.1 30.3 2.8 0.6
Bogor 219 48.4 31.1 20.5 207 12.6 61.4 1.9 23.7 0.5 0.0
Sukabumi 220 34.5 47.3 18.2 195 9.2 51.3 14.4 24.6 0.5 0.0
West Bandung 220 52.7 34.5 12.7 220 5.0 65.9 0.0 28.6 0.0 0.5
Sukabumi City 214 34.1 58.4 7.5 209 1.4 82.3 1.0 13.9 0.0 1.4
Bandung City 219 63.9 24.2 11.9 217 3.7 78.3 3.7 12.9 0.5 0.9
Bekasi City 215 47.0 28.4 24.7 213 13.1 59.2 2.8 23.9 0.0 0.9
Depok City 218 32.1 54.1 13.8 210 7.6 45.2 6.2 33.3 7.6 0.0
Salatiga City 104 58.7 32.7 8.7 103 7.8 59.2 0.0 30.1 2.9 0.0
Yogyakarta City# 16 25.0 62.5 12.5 16 12.5 37.5 0.0 43.8 6.3 0.0
Kota Tangerang# 36 47.2 19.4 33.3 34 2.9 79.4 0.0 14.7 0.0 2.9
Tangerang
43 58.1 27.9 14.0 37 5.4 67.6 2.7 24.3 0.0 0.0
Selatan City#
Badung# 84 31.0 52.4 16.7 82 23.2 37.8 0.0 36.6 1.2 1.2
Kupang City# 4 25.0 75.0 0.0 3 0.0 66.7 0.0 33.3 0.0 0.0
Makassar City 220 61.8 29.1 9.1 220 1.8 74.5 1.8 17.3 0.5 4.1
Aggregate 2029 46.1 39.4 14.5 1972 6.9 63.6 3.8 23.4 1.4 0.9
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Almost half of PWID respondents stated they were unmarried (46.1%), and a third (39.4%)
acknowledged to have been married and were either living together with or separately from their
spouse. Interestingly, half of the unmarried PWID (51.6%) were 25 to 49 years old and a third
(31.7%) were 20 to 24 years old.

189
 At the time of the interview, almost all PWID (96.82%) had a permanent place to live, which was
defined as a house, rented house or room where respondents lived. More than half lived with
their family or sibling (63.60%) and almost a quarter (23.4%) lived with their wife/partner. This
survey focused its attention on PWID without a permanent place to live as studies have shown
that lack of permanent place to live is one risk factor that plays a significant role in the formation
of a substance abuse network (Boodram, Mackesy-Amiti, Latkin, 2015). In this survey, around 4%
of respondents may be able to form a substance abuse network in their neighborhood.

Table 7.5 Employment and Health Insurance Coverage of PWID

Employment of PWID (%) Health Insurance Coverage (%)

Circumcision
District / Job with Government
n Free-lance Drug Status Government Private No
Municipality Unemployed steady n and private
Work Courier (%) insurance insurance insurance
income insurance
Banda Aceh City# 15 33.3 40.0 26.7 0.0 100.0 14 100.0 0.0 0.0 0.0

Padang City# 76 28.9 28.9 42.1 0.0 98.7 52 67.3 0.0 1.9 30.8

Bandar Lampung 57 7.0 80.7 12.3 0.0 80.7 66.7 3.7 1.9 27.8
54
City#
East Jakarta City 180 18.3 64.4 17.2 0.0 83.9 176 67.6 14.8 2.3 15.3

Bogor 219 21.9 50.7 25.6 1.8 98.6 213 36.6 3.8 3.8 55.9

Sukabumi 220 12.7 43.6 41.4 2.3 98.6 209 52.2 1.4 2.9 43.5

West Bandung 220 7.7 41.4 50.9 0.0 96.4 217 42.4 8.8 3.2 45.6

Sukabumi City 214 16.4 31.3 52.3 0.0 97.2 209 67.9 0.0 0.0 32.1

Bandung City 219 19.2 37.9 42.9 0.0 96.8 187 52.9 0.0 0.5 46.5

Bekasi City 215 5.6 63.7 30.2 0.5 98.6 211 63.0 10.4 2.8 23.7

Depok City 218 15.6 37.6 46.8 0.0 97.7 201 59.2 11.4 3.0 26.4

Salatiga City 104 17.3 76.9 5.8 0.0 97.1 104 55.8 2.9 3.8 37.5

Yogyakarta City# 16 6.3 62.5 31.3 0.0 87.5 16 87.5 0.0 0.0 12.5

Tangerang City# 36 8.3 47.2 44.4 0.0 88.9 34 58.8 0.0 14.7 26.5

South Tangerang 43 16.3 34.9 48.8 0.0 95.3 67.6 2.9 0.0 29.4
34
City#
Badung# 84 6.0 61.9 32.1 0.0 63.1 82 26.8 0.0 3.7 69.5

Kupang City# 4 25.0 25.0 50.0 0.0 50.0 3 66.7 33.3 0.0 0.0

Makassar City# 220 38.6 38.2 23.2 0.0 98.6 172 65.7 0.0 0.6 33.7

Aggregate 2029 17.3 46.7 35.5 0.5 96.6 1899 55.9 5.5 2.3 36.3
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Type of employment has a large influence on one’s ability to own a health insurance so the survey
looked at the occupation that PWID had. More than a third of PWID were unemployed (17.3%)
while almost half had a salaried job (46.7%). Within these two categories, quite a lot of PWID did
not have any health insurance, either the government insurance/BPJS (44.4%) or private
insurance (45.9%). Among PWID who obtained income as a drug courier, the proportion of those
without health insurance was even higher (60.0%).

190
 The majority of male PWID were also circumcised (96.6%), and the survey showed that the risk
for HIV infection among uncircumcised respondents was 2.1 times greater than the risk among
circumcised respondents (95% CI 1.2-3.7). From the estimated 50 million people that have been
infected with HIV globally, around half were men, who were mostly infected through their penis.
In primary HIV infection that occurs in men, the inner surface of the penis’s foreskin, which is rich
in HIV receptors, and the frenulum, which generally experiences friction during sexual
intercourse, is regarded as the most probable site for entry of virus and other STIs (Szabo and
Short, 2000).

7.2 HIV Knowledge, Risk Perception and Protective Behavior

7.2.1. Knowledge about HIV

Respondents’ knowledge about HIV was assessed through five questions on whether they knew
that an individual who looks healthy can be HIV positive, whether they knew how to prevent HIV
infection, and whether they rejected several misconceptions regarding HIV transmission that
have been circulating in the general population. The five questions, each of equal weight, were
then combined into one variable of comprehensive knowledge. A respondent would be
categorized as having comprehensive knowledge if he/she responded correctly to all five
questions.

Table 7.6 PWID’s Knowledge about HIV

Knowledge about HIV
A Healthy- HIV Prevention HIV Transmission
Know about Comprehensive
looking HIV is not HIV is not
District / HIV before Reduce HIV Reduce HIV Risk
n Individual transmitted transmitted Knowledge
Municipality the interview Risk by Using by Being Faithful
can be through by sharing (%)
(%) Condom to Partner
HIV- mosquito/ food
(%) (%)
Infected insect bite (%) (%)
Banda Aceh City# 15 60.0 53.3 73.3 66.7 0.0 0.0 46.7

Padang City #
76 30.3 23.7 51.3 44.7 14.5 15.8 15.8

Bandar Lampung 57 82.5 86.0 82.5 80.7 12.3 22.8 40.4

City#
East Jakarta City 180 96.1 90.6 95.6 95.0 1.1 4.4 85.0

Bogor 219 86.8 70.3 79.0 81.7 6.4 6.4 46.6

Sukabumi 220 72.3 60.9 69.5 69.1 4.1 4.5 50.0

West Bandung 220 94.1 90.5 96.8 95.9 7.3 16.4 70.0

Sukabumi City 214 88.3 87.9 95.8 94.4 15.9 18.2 69.2

Bandung City 219 89.5 74.0 90.4 86.3 28.8 34.2 30.6

Bekasi City 215 86.5 78.6 86.5 82.8 7.9 9.3 66.0

Depok City 218 75.2 75.2 82.6 87.6 9.2 11.5 59.2

Salatiga City 104 81.7 35.6 77.9 77.9 26.0 23.1 15.4

191
 Knowledge about HIV

A Healthy- HIV Prevention HIV Transmission

Know about Comprehensive
District / HIV before looking
n HIV is not HIV is not Knowledge
Municipality the interview Individual Reduce HIV Reduce HIV Risk
transmitted transmitted (%)
(%) can be Risk by Using by Being Faithful
through by sharing
HIV- Condom to Partner
mosquito/ food
Infected (%) (%)
insect bite (%) (%)
Yogyakarta City 16 93.8 93.8 93.8 93.8 0.0 0.0 81.3

Tangerang City 36 94.4 36.1 72.2 94.4 2.8 11.1 25.0

South Tangerang 43 53.5 88.4 83.7 2.3 16.3 39.5

67.4
City#
Badung# 84 91.7 83.3 96.4 90.5 19.0 22.6 48.8

Kupang City#
4 100.0 100.0 100.0 100.0 0.0 0.0 100.0

Makassar City 220 75.9 81.4 86.8 87.7 7.7 11.8 65.0

Aggregate 2029 84.6 76.3 86.3 86.1 76.1 77.6 57.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

As an aggregate, 84.6% of PWID had already received information about HIV prior to the survey
interview. This finding was consistent with the finding on level of respondent’s knowledge in
which 86% of respondents gave a correct answer to questions.

Only around 76.3% of respondents knew that a healthy-looking person can actually be HIV-
infected, and around 86% of respondents knew that HIV can be prevented by using condom
during sex and by being faithful to one’s partner. Correct answers to misconceptions that HIV is
transmitted through mosquito bite and by sharing food were provided by 76-77% respondents.
This number shows that there is some stigma around HIV transmission.

In the composite variable on knowledge, only 57.4% of respondents answered correctly to all five
questions. This was a relatively low percentage as that indicated that almost half of PWID had
incorrect knowledge about HIV prevention and transmission. This incorrect knowledge would
affect respondents’ behavior such as in condom use consistency during sex. The percentage of
consistent condom use was indeed higher (27.8%) among respondents with comprehensive
knowledge compared to the consistency among respondents with no comprehensive knowledge
(13.4%).

7.2.2 Risk Perception and Protective Behavior

This next table presents data on respondents’ risk perception and actions that they did to protect
themselves from HIV infection.

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 Table 7.7 Risk Perception and Protective Behavior of PWID
Reason for feeling at risk* Protective Behavior to Prevent HIV
Risk Had Be faithful
Had used non- Had Always Do not share
District / Municipality n Perception received Other to sex
sterile unprotected use
(%) blood non-sterile
injection sex (%) condom partner
transfusion (%) needles (%)
device (%) (%) (%)
(%)
Banda Aceh City# 15 46.7 71.4 85.7 14.3 71.4 93.3 73.3 86.7
Padang City# 76 26.3 60.0 75.0 10.0 60.0 44.7 40.8 38.2
Bandar Lampung City# 57 68.4 97.4 48.7 2.6 97.4 57.9 54.4 68.4
East Jakarta City 180 95.0 94.7 81.3 4.7 94.7 83.3 86.1 90.0
Bogor 219 78.1 97.7 18.1 2.9 97.7 89.0 86.8 87.2
Sukabumi 220 45.5 78.0 88.0 6.0 78.0 83.2 75.0 74.5
West Bandung 220 79.5 96.0 84.0 5.7 96.0 88.2 84.1 88.6
Sukabumi City 214 93.9 99.0 78.1 2.5 99.0 95.8 78.5 80.8
Bandung City 219 67.1 89.8 47.6 0.0 89.8 60.3 61.6 91.8
Bekasi City 215 64.7 94.2 66.2 9.4 94.2 68.4 60.5 81.9
Depok City 218 67.4 86.4 55.1 1.4 86.4 56.9 61.9 83.9
Salatiga City 104 23.1 70.8 45.8 12.5 70.8 33.7 39.4 45.2
Yogyakarta City# 16 62.5 90.0 80.0 30.0 90.0 93.8 93.8 93.8
#
Tangerang City 36 94.4 97.1 67.6 11.8 97.1 97.2 91.7 86.1
Tangerang Selatan City# 43 65.1 85.7 39.3 3.6 85.7 58.1 46.5 69.8
Badung# 84 51.2 74.4 74.4 25.6 74.4 79.8 84.5 89.3
Kupang City# 4 75.0 33.3 100.0 0.0 33.3 100.0 75.0 100.0
Makassar City 2 220 77.3 91.2 41.2 0.6 91.2 40.0 40.0 94.1
Aggregate 2029 71.2 92.5 61.3 3.7 0.9 71.6 68.6 83.7
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who perceived themselves to be at risk

About 71.2% of respondents perceived themselves to be at risk of HIV infection, and the most
common reason stated (92.5%) was because they had used unsterile needle in the past. PWID
also frequently had unprotected sex (61.3%). When asked about any protective behavior, the
majority of respondents (83.7%) stated that they did not share needles.

Perception is important to increase one’s awareness and improve their protective behavior.
When an individual realizes he/she is at risk, naturally they will take preventive actions. A study
done by Koku and Felsher (2019) reported that the perception of risk for HIV is a product of
individual characteristics, interpersonal relationship and social network. At the individual level,
HIV risk perception is linked with sex/gender (women’s risk perception is lower than men’s), and
risk behaviors (unsafe sex, substance abuse, needle sharing). Risk perception is also influenced
by interpersonal relationship. An individual’s risk perception will increase if peers in their group
are at risk. Social network plays a role in risk perception by lowering one’s risk perception
whenever the individual is part of a homogeneous group (one ethnic group, one race, etc.).

193
 7.3 Injecting Drug Use
7.3.1 Age at First Injection and Length of Drug Use

The age an individual started using drugs and the length of drug use is one important indicator to
identify the risk for HIV and Hepatitis infection.

Table 7.8 Age at First Injection and Length of Drug Use among PWID
Length of Injecting Drug Ever Experienced
Age at First Injection
District/Municipality n Use (in months) Overdose
median median (%)
Banda Aceh City# 15 18.1 38 13.3

Padang City# 76 20 25 1.3

Bandar Lampung City# 57 20 74 24.6

East Jakarta City 180 20 120 27.8

Bogor 219 21.5 145 16.9

Sukabumi 220 25 24 5.5

West Bandung 220 21 60 15.0

Sukabumi City 214 17.7 120 15.4

Bandung City 219 18.1 30 12.8

Bekasi City 215 18.1 120 20.9

Depok City 218 23 41 12.4

Salatiga City 104 18 82 16.3

Yogyakarta City# 16 19.1 97 37.5

Tangerang City# 36 18.4 84 30.6

South Tangerang City# 43 18.5 74 27.9

Badung# 84 19.9 138 23.8

Kupang City# 4 19.9 76.5 75.0

Makassar City 220 19 48 9.5

Aggregate 2029 20 62 14.9

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The median age of first drug injection was 20 years, demonstrating that injecting drug use started
at an early age. In Salatiga City, the median age was 18, which was even younger. The younger an
individual started using drugs, the more likely (1.44 times) they would adopt high-risk behaviors
such as needle sharing (Adjusted Odds Ratio/AOR 1.44; 95%CI 1.06-1.88) (Janssen, Shah, Néfau,
Cadet-Taïrou, 2019).

The median length of drug use among PWID was 62 months or around 5 years. At the time of the
survey, 51.1% of respondents had been using drugs for more than five years, while the longer an
individual has been injecting drug, the more frequent he/she has been exposed to needles that
may contain the HIV and Hepatitis virus. This was confirmed by the result of a cross-tabulation
analysis between the length of drug use and HIV incidence that showed significant association

194
 with a prevalence odds ratio (POR) of 5.8 (95% CI 4.2-8.1. A similar result was obtained for
Hepatitis C with an association of 1.5 (POR 1.5; 95% CI 1.3-1.8).

7.3.2 Type of Injectable Drugs Used

The next table lists the types of injectable drugs used by PWID respondents.

Table 7.9 Type of Injectable Drugs Used by PWID

Type of Injectable Drugs Used (%)*
District /
n Ampheta- Benzodia
Municipality Heroin Diazepam Suboxone Methadone Ketamine Fentanyl Fentidine Other
mine - zepine
Banda Aceh
15 26.7 33.3 46.7 6.7 20.0 0.0 6.7 0.0 0.0 0.0
City#
Padang City# 76 22.4 5.3 35.5 5.3 1.3 5.3 0.0 0.0 19.7 2.6
Bandar 7.0
57 57.9 35.1 24.6 24.6 3.5 10.5 3.5 0.0 17.5
Lampung City#
East Jakarta
180 61.1 6.1 13.9 53.9 0.6 0.0 14.4 3.3 0.6 2.8
City
Bogor 219 12.3 31.1 37.9 74.0 11.9 3.2 47.9 11.4 0.5 3.7
Sukabumi 220 5.5 4.1 37.3 5.9 7.7 0.5 24.1 0.0 1.8 9.1
West Bandung 220 35.0 0.5 2.7 70.5 1.4 0.0 2.3 0.5 0.0 0.0
Sukabumi City 214 85.5 53.7 27.1 33.6 0.9 0.0 7.5 2.8 0.5 34.1
Bandung City 219 10.0 2.7 0.9 94.1 0.5 0.5 10.5 0.5 0.5 0.0
Bekasi City 215 56.3 4.7 20.5 53.0 2.3 2.3 1.4 0.0 0.0 0.0
Depok City 218 21.1 5.0 8.7 77.5 11.5 0.0 19.3 0.9 0.0 0.5
Salatiga City 104 45.2 12.5 23.1 43.3 14.4 0.0 5.8 0.0 0.0 0.0
Yogyakarta 25.0
16 12.5 68.8 25.0 31.3 6.3 56.3 25.0 0.0 6.3
City#
Tangerang 2.8
36 58.3 22.2 27.8 0.0 13.9 25.0 5.6 0.0 0.0
City#
South
Tangerang 43 39.5 27.9 11.6 60.5 23.3 4.7 32.6 9.3 0.0 9.3
City#
Badung# 84 40.5 9.5 11.9 63.1 4.8 2.4 15.5 1.2 1.2 1.2
Kupang City# 4 25.0 50.0 50.0 0.0 0.0 0.0 50.0 0.0 0.0 0.0
Makassar City 220 2.3 3.2 96.8 7.3 2.3 0.5 0.0 1.4 0.0 1.8
Aggregate 2029 32 12.4 27.4 51.7 4.9 0.7 14.0 2.2 5.5 0.4
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The most commonly used drug was Suboxone. Based on a report by Rumah Cemara, suboxone or
the slang word “bukson” is a drug that has the same function as methadone and is used in opioid
substitution therapy. Suboxone is administered orally as a way to reduce the number of injecting
opioid users, but with time, the rate of suboxone abuse increased, and it became an injectable
drug. A study in Denpasar reported that determinants of suboxone abuse included limited control
by health care providers, and inadequate regulation about prescription of suboxone, its safety
and legality. Economic factors and individual motivation also played a role, along with limited
access to accurate information, plus social and environmental context (Yasmari et al., 2016).

195
 7.3.3 Injection Frequency and Needle Use Practices

The table below presents the frequency of injection that respondents had on the day they last
injected drugs, also information about needle sharing and injection practices of respondents on
their last injection session. In this survey, respondents were asked about their needle use practice
in the last week and their needle sharing behaviors in the last month.

Table 7.10 Injection Frequency on the Last Day of Injection and Needle Use Practices

On the Last Day of Injection Consistently

Shared
Frequency of Injection (%) used non-
needle in
Shared Used non- sterile needle
District / Municipality n n n the last
2-3 >3 needles sterile needles in the last
median 1 time month
times times (%) (%) week
(%)
(%)
Banda Aceh City# 15 3 13.3 73.3 13.3 20.0 13.3 15 6.7 3 100.0

Padang City# 76 1 92.1 7.9 0.0 2.6 0.0 76 1.3 1 0.0

Bandar Lampung City# 57 2 45.6 45.6 8.8 14.0 15.8 57 10.5 33 18.2

East Jakarta City 180 2 29.6 63.7 6.7 15.1 20.7 180 2.2 87 23.0

Bogor 219 3 11.9 72.5 15.6 5.5 6.4 219 0.0 174 54.6

Sukabumi 220 1 70.5 27.3 2.3 1.7 4.0 220 0.5 37 43.2
West Bandung 220 2 45.5 53.2 1.4 6.8 11.4 220 0.0 97 64.9

Sukabumi City 214 2 37.9 60.7 1.4 10.7 9.8 214 0.9 149 61.1
Bandung City 219 1 52.1 41.6 6.4 15.5 19.2 219 2.3 207 61.8

Bekasi City 215 2 44.7 50.7 4.7 4.2 4.2 215 0.9 171 10.5

Depok City 218 1.5 50.0 46.3 3.7 6.9 5.0 218 0.5 171 35.7
Salatiga City 104 1 67.3 29.8 2.9 16.3 15.4 104 4.8 49 18.4

Yogyakarta City# 16 1 75.0 12.5 12.5 6.3 0.0 16 0.0 1 0.0

Tangerang City# 36 2 41.7 41.7 16.7 25.0 27.8 36 2.8 15 80.0

South Tangerang City# 43 1 55.8 25.6 18.6 9.3 7.0 43 4.7 36 52.8
Badung# 84 1 53.6 40.5 6.0 9.5 1.2 84 1.2 49 8.2

Kupang City# 4 1 75.0 0.0 25.0 25.0 0.0 4 0.0 NA NA

Makassar City 220 2 46.8 48.6 4.5 11.8 9.1 220 5.0 151 22.5
Aggregate 1983 2 44.2 37.1 18.8 9.1 10.2 2029 1.5 1293 41.4
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

On the day respondents had their last injection, the median frequency of injection was two times,
while around 55.8% of respondents injected more than twice. During that last injection session,
around 9.1% of respondents shared needles and 10.2% used non-sterile (used) needles. In the
last week, 1.5% of respondents consistently used non-sterile needles. Eventhough this was a
relatively small percentage, but any use of non-sterile needle would place the individual at a
higher risk for HIV infection (POR 2.2).

Around 41% of PWID also shared needles in the last month. This showed that needle sharing was
a common practice among PWID.

196
 7.3.4 Injection Venue and Source of Injection Needle

Table 7.11 lists the venues or locations that respondents commonly used to inject drugs in the
last week. During the interview respondents mentioned a total of 17 locations. The top 6 were
selected and presented here. Table 7.11 also lists places where respondents obtained or
purchased injection needles in the last week.

Table 7.11 Injection Venue and Source of Needle for PWID

Injection Venue in the Last Week (%) Source of Needles in the Last Week (%)
Public
District / Own Friend’s Drug/ Animal Friend/
n* Toilet Drug
Municipality Home/ Home/ Empty Personal Drug Medical Feed Relative
(mall/ Dealer’s NSEP
Rental Rental House Car Dealer Device Store/ Supply (other
restaurant/ Home
Room Room Pharmacy Store PWID)
store)
Banda Aceh
3 66.7 33.3 66.7 66.7 33.3 66.7 66.7 66.7 33.3 33.3 0.0
City#
Padang City# 1 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0
Bandar
33 66.7 42.4 3.0 0.0 0.0 0.0 9.1 57.6 0.0 18.2 12.1
Lampung City#
East Jakarta
87 85.1 17.2 10.3 2.3 5.7 4.6 2.3 28.7 1.1 9.2 65.5
City
Bogor 174 87.9 67.8 5.7 16.1 4.6 0.6 33.9 29.3 2.3 32.8 51.7

Sukabumi 37 64.9 27.0 0.0 0.0 0.0 0.0 37.8 29.7 0.0 5.4 5.4

West Bandung 97 51.5 75.3 6.2 7.2 9.3 0.0 30.9 23.7 0.0 62.9 9.3
Sukabumi City 149 22.8 79.2 41.6 0.7 0.0 2.7 0.0 55.7 1.3 6.7 81.9

Bandung City 207 74.9 46.9 12.1 1.4 3.9 0.5 1.9 33.8 0.0 13.0 65.2

Bekasi City 171 86.0 62.0 0.6 4.7 2.9 12.3 17.5 36.3 0.6 38.6 35.7

Depok City 171 76.6 57.9 2.9 9.9 5.3 0.0 20.5 27.5 0.0 43.3 38.6

Salatiga City 49 79.6 55.1 0.0 6.1 0.0 0.0 2.0 36.7 10.2 32.7 22.4
Yogyakarta
1 100.0 100.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.0 100.0
City#
Tangerang City# 15 86.7 66.7 46.7 40.0 33.3 6.7 26.7 73.3 26.7 6.7 66.7
South
Tangerang 36 41.7 25.0 25.0 0.0 5.6 0.0 8.3 69.4 13.9 8.3 11.1
City#
Badung# 49 44.9 42.9 8.2 0.0 8.2 10.2 4.1 36.7 6.1 10.2 49.0
Kupang City#

Makassar City 151 49.7 45.7 7.9 3.3 19.9 7.9 1.3 63.6 4.6 21.9 21.9

Aggregate 1293 68.2 56.6 10.1 5.7 5.7 3.3 13.7 37.6 1.5 27.4 45.3
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who injected drugs in the last month; NSEP = Needle and Syringe Exchange Program

In the last week, most PWID respondents did their injection in a private place such as their own
home/apartment/rental room (68.2%) or private places that belonged to a friend (56.5%). Some
also did their injection in public venues that may be less conducive such as public toilet (10.1%)
and an empty unoccupied house (5.7%). Injecting drug in such places actually increases the risk
of overdose which, without prompt treatment by a health provider, can be fatal. Therefore, in
some countries, for example in Canada, a specific injecting venue is established called Safe

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Injection Site/Supervised Injection Services (SIS). SIS provides a clean, safe, supervised
environment where PWID can inject drugs they had obtained, and can be linked to health care
and public services. SIS contains several cubicles where PWID are continuously monitored by a
health professional (Bowers, 2019).

Regarding the source of injection needle, 45.3% of respondents reported receiving needles from
the Needle and Syringe Exchange Program (NSEP/LASS). NSEP is a program that provides sterile
injection devices and encourage PWID to use those sterile devices. The program also assists in
disposal of used injection devices to reduce the risk of needle sharing and disease transmission
through improper disposal of non-sterile needles. In implementing NSEP, it is important to also
identify conditions that can hamper PWID’s ability to practice safe injection and implement
appropriate interventions.

In Indonesia the needle syringe exchange program is one of the main components in the HIV
intervention program. It is targeted toward high-risk group of people who inject drugs, and is
implemented by Puskesmas and NGOs. The program utilizes two approaches: a static approach
(Puskesmas, NGO’s drop-in center) and mobile approach (field outreach worker). The NSEP
package that is given to PWID contains 3 sterile syringes and needles, 3 alcohol swab sachets, 3
condoms and IEC material.

Information on the NSEP and the number of needles received is summarized in Table 7.12 below.

Table 7. 12 Number of Needles Received from the NSEP Program and Abscess at the Injection Site
Number of Needles Received from NSEP at these facilities Abscess at the
District / Municipality n* (median) n injection site
Puskesmas NGO’s Drop-in Center NGO Staff NSEP Post (%)
Banda Aceh City# 0 NA NA NA NA 15 13.3

Padang City# 0 NA NA NA NA 76 19.7

Bandar Lampung City# 4 5 0 0 0 57 29.8
East Jakarta City 57 5 0 3 0 180 46.7
Bogor 90 0 21 0 21 219 52.1
Sukabumi 2 2 1.5 1.5 1.5 220 3.2
West Bandung 9 0 0 3 0 220 21.4
Sukabumi City 122 5 0 3 6 214 41.6
Bandung City 135 3 0 0 0 219 70.3
Bekasi City 61 4 4 4 0 215 31.2
Depok City 66 10 0 0 0 218 22.5
Salatiga City 11 0 0 0 0 104 15.4
Yogyakarta City# 1 5 0 0 0 16 37.5
Tangerang City# 10 3 3 3 3 36 25.0
South Tangerang City# 4 6.5 0 0 0 43 53.5
Badung# 24 0 0 5 0 84 27.4
Kupang City# 0 NA NA NA NA 4 50.0
Makassar City 33 0 0 6 0 220 36.8
Aggregate 577 3.8 1.9 2.1 2.4 2029 34.9
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who received needles from the NSEP

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The median number of sterile needles that respondents received from the NSEP ranged from 1.9
to 3.8. The most was obtained from Puskesmas. A third of respondents reported experiencing
abscess at the injection site, indicating the presence of infection from bacteria in unsterile
needles.

7.3.5 Correctional Facilities and Drugs

It is well recognized that substance abuse is a criminal act, and the survey therefore tried to
illustrate the number of respondents who are imprisoned because of that. The information is also
important for HIV program implementation in correctional facility, since it is another venue
where HIV transmission is taking place.

Table 7.13 Imprisonment due to Substance Abuse and HIV Program Implementation in Prison

Imprisoned due to
Injected Drugs while in Received sterile needles
District / Municipality n Substance Abuse n*
Prison (%) in prison (%)
(%)
Banda Aceh City# 15 0.0
Padang City# 76 3.9 3 33.3 0.0
Bandar Lampung City# 57 17.5 10 20.0 0.0

East Jakarta City 180 45.0 81 46.9 1.2

Bogor 219 23.7 52 65.4 0.0
Sukabumi 220 6.4 14 28.6 0.0
West Bandung 220 8.2 18 5.6 0.0

Sukabumi City 214 26.2 56 71.4 0.0

Bandung City 219 8.7 19 26.3 5.3

Bekasi City 215 13.0 28 71.4 7.1

Depok City 218 5.5 12 58.3

Salatiga City 104 1.9 2 0.0

Yogyakarta City# 16 31.3 5 80.0

Tangerang City# 36 30.6 11 45.5 0.0

43
Tangerang Selatan City# 20.9 9 77.8

Badung# 84 23.8 20 60.0

Kupang City# 4 0.0
Makassar City 33 17.7 39 74.4 2.6
Aggregate 577 15.8 321 55.5 1.6
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who had been imprisoned due to substance abuse;

As a result of substance abuse 15.8% PWID were imprisoned, and half of them continued injecting
drugs in prison (55.5%). As stated by respondents, 1.6% of them received sterile needles in
prison.

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7.4 Sexual Behavior and Condom Use
7.4.1 Age at First Sexual Intercourse

The aggregate analysis showed that 92.9% of 2029 PWID respondents have had sexual
intercourse. The survey then probed for the age of first sexual intercourse.

Table 7. 14 Age of First Sexual Intercourse among PWID

Age of First Sexual Intercourse (%)*
District / Municipality n Median
≤ 14 years 15-17 years 18-24 years ≥25 years
Banda Aceh City# 11 18 18.2 27.3 45.5 9.1
Padang City# 48 20 0.0 33.3 54.2 12.5
Bandar Lampung City# 51 19 0.0 33.3 56.9 9.8

East Jakarta City 172 18 4.7 43.3 41.5 10.5

Bogor 184 19 6.6 31.5 55.2 6.6

Sukabumi 211 20 0.9 18.0 66.8 14.2

West Bandung 213 20 0.5 16.0 71.8 11.7

Sukabumi City 209 17 4.3 65.2 27.5 2.9

Bandung City 196 17 8.3 50.0 39.6 2.1

Bekasi City 201 17 4.5 54.7 39.3 1.5

Depok City 194 20 1.5 17.0 58.2 23.2

Salatiga City 100 17 10.0 44.0 39.0 7.0

Yogyakarta City# 15 17 20.0 46.7 26.7 6.7

Tangerang City# 36 18.5 5.6 27.8 52.8 13.9

Tangerang Selatan City# 43 17 14.0 51.2 27.9 7.0
Badung# 82 18 4.9 32.9 50.0 12.2
Kupang City# 4 17 25.0 25.0 50.0 0.0

Makassar City 205 17 6.8 51.2 41.0 1.0

Aggregate 1885 18 4.5 38.7 48.7 8.1
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who have had sex

The median age of first sexual intercourse among PWID was 18 years. Almost half of respondents
had their first sex between the age of 18 to 24 (48.7%) but a small proportion also started very
early at younger than 14 years (4.5%). Age of first sexual intercourse is an important variable for
public health policymakers as it is linked with certain unhealthy behaviors, like unsafe sex during
the first sexual experience, inappropriate condom use or having multiple partners (concurrently
or from time to time throughout their life). All these behaviors can result in increased rate of
sexually-transmitted infection, teen pregnancy, and adverse psychological consequences such as
disappointment, regret, etc. (de Iral et al., 2011).

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 7.4.2 Condom and Sexual Behavior

Use of condom is an important part of HIV/AIDS prevention. Unfortunately, when the interviewer showed
a condom to PWID respondents, only 94.4% of them knew about condom such that the data presented
here are data on respondents who knew about condom.

Table 7.15 Ways to Obtain Condom, Places the Sell Condom and Places that Provide Free Condom

Ways to Obtain Condom in the Last Month* Places that Sell Condom** Places that Provide Free Condom***
(%) (%) (%)
District /
Did not Received Bought and
Municipality Bought Pharmacy/ Health Outreach
n have free received free n Shops n Friends NGO
condom Drug Store Facility worker
condom condom condom
Banda
12 41.7 41.7 8.3 8.3 6 16.7 83.3 7 28.6 42.9 14.3 0.0
Aceh City#
Padang City# 56 37.5 51.8 5.4 5.4 32 0.0 96.9 6 33.3 0.0 66.7 0.0
Bandar
55 40.0 32.7 21.8 5.5 21 57.1 42.9 15 66.7 13.3 20.0 0.0
Lampung City#
East Jakarta
173 24.9 6.4 55.5 13.3 34 29.4 67.6 119 38.7 1.7 58.0 1.7
City
Bogor 168 46.4 4.8 44.0 4.8 16 75.0 25.0 88 8.0 3.4 88.6 0.0

Sukabumi 206 38.8 10.2 41.7 9.2 40 77.5 22.5 117 6.0 3.4 88.0 2.6

West Bandung 219 60.3 12.3 15.1 12.3 54 68.5 29.6 70 11.4 14.3 74.3 0.0

Sukabumi City 20 55.8 23.6 9.1 11.5 73 8.2 91.8 69 42.0 21.7 34.8 0.0

Bandung City 218 62.8 7.3 24.8 5.0 27 51.9 48.1 74 27.0 14.9 51.4 6.8

Bekasi City 195 51.3 28.7 15.4 4.6 65 21.5 76.9 40 22.5 2.5 75.0 0.0

Depok City 210 54.3 9.0 27.6 9.0 38 36.8 60.5 77 37.7 11.7 23.4 26.0

Salatiga City 101 53.5 11.9 29.7 5.0 17 88.2 5.9 35 8.6 40.0 51.4 0.0
Yogyakarta
16 18.8 43.8 37.5 0.0 7 14.3 85.7 7 28.6 0.0 42.9 28.6
City#
Tangerang
35 14.3 31.4 40.0 14.3 16 50.0 25.0 19 0.0 0.0 100.0 0.0
City#
South
Tangerang 38 42.1 28.9 13.2 15.8 17 47.1 52.9 11 18.2 0.0 81.8 0.0
City#
Badung# 84 25.0 29.8 31.0 14.3 37 43.2 54.1 38 21.1 0.0 78.9 0.0

Kupang City# 4 75.0 0.0 0.0 25.0 1 100.0 0.0 1 0.0 100.0 0.0 0.0

Makassar City 218 62.4 8.7 23.9 5.0 30 3.3 96.7 63 12.7 11.1 76.2 0.0

Aggregate 1916 51.7 12.4 27.8 8.1 394 39.1 59.6 752 22.1 10.1 63.6 4.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; * Among
respondents who know about condom; **Among respondents who buy condom; The sum in each row does not add to 100% since
some categories with very low percentage are not presented; ***Among respondents who obtain free condom; The sum in each row
does not add to 100% since some categories with very low percentage are not presented.

About 5.6% of respondents did not know what condom is, which correlated with their sexual
experience. About 27.8% of respondents have never had sex, so they did not know what condom
is. However, among respondents who have had sex, there was still 3.9% who did not know about
condom.

In the last month 51.7% of respondents did not have condom, 27.8% obtained condom free of
charge, 12.4% bought condom, and 8.1% bought and got free condom. Most of PWID who

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 received free condom was found in East Jakarta City (55.5%). On average the number of free
condoms was 12.9.

Among respondents who bought condom, the majority went to a pharmacy/drug store (59.6%)
while 39.1% bought condom from a shop. This showed that condoms are freely available and
easily accessed.

Among respondents who obtained free condom, the majority would receive them from NGOs
(63.6%). This showed that outreach by NGO to PWID was very good.

7.4.2.1 Steady and Non-Steady Partner

This section presents information on risk behavior of PWID, namely sexual behavior and use of
condom with two different types of sex partner: steady and non-steady partner in the context of
heterosexual sex. Data presented were on condom use during the last sex and condom use
consistency during sex in the last month. In this survey, consistent was defined as ‘frequently’ and
‘always’ using condom during sex.

Information about condom use is important considering use of drugs can prompt someone to
engage in risky sex behavior that will increase the risk for HIV infection.

Table 7.16 PWID’s Sexual Behavior and Condom Use with Steady and Non-Steady Partner
Steady Partner Non-Steady Partner
Used Condom in Use Condom Used Condom in Use Condom
District / Municipality N* Have Condom Have Condom
Last Sex** Consistently*** Last Sex*** Consistently***
(%) (%)
(%) (%) (%) (%)
Banda Aceh City# 11 27.3 0.0 0.0 9.1 0.0 0.0
Padang City# 48 70.8 36.7 37.0 33.3 43.8 35.7
Bandar Lampung City# 51 80.4 65.0 62.2 23.5 58.3 42.9
East Jakarta City 172 66.3 26.7 21.2 25.6 34.1 27.6
Bogor 184 38.0 8.6 4.2 25.0 13.0 11.1
Sukabumi 211 44.5 57.0 28.1 27.0 59.6 14.7
West Bandung 213 47.4 26.0 6.5 16.4 25.7 4.0
Sukabumi City 209 51.2 34.4 21.0 21.1 45.5 25.8
Bandung City 196 70.9 30.7 14.8 12.2 29.2 13.3
Bekasi City 201 42.3 64.6 60.5 11.9 54.2 23.5
Depok City 194 64.4 38.7 25.5 24.2 34.0 11.1
Salatiga City 100 73.0 17.4 14.5 7.0 42.9 66.7
Yogyakarta City# 15 86.7 50.0 58.3 20.0 66.7 66.7
Kota Tangerang# 36 25.0 50.0 50.0 36.1 38.5 100.0
Tangerang Selatan City# 43 58.1 38.1 21.1 16.3 28.6 0.0
Badung# 82 70.7 44.6 40.0 13.4 63.6 50.0
Kupang City# 4 100.0 0.0 0.0 75.0 0.0 33.3
Makassar City 205 65.9 32.5 7.3 11.7 25.0 18.8
Aggregate 1885 55.3 34.1 22.4 18.7 36.6 17.7
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who have had sex; **Among respondents who had sex in the last year; ***Among respondents who had sex in the last
year.

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 Some PWID respondents mentioned that they had a steady sex partner (55.3%). Cross-tabulation
with marital status showed that what they meant as steady sex partner for 65.9% of them was
their wife/husband, and for the rest of PWID, steady sex partner would be their girl/boyfriend.
In general, condom use with a steady partner was low, i.e. 34.1% during respondent’s last sex,
and only 22.4% in consistency in the last month.

About 18.7% of respondents also had a non-steady sex partner. A look at respondent’s marital
status revealed that 70.8% of respondents were either unmarried or divorced. The rest, 29.2%
were married. The median number of steady partners in the last year was two. The low
proportion of respondents with non-steady partner and the low median number of non-steady
partner showed that PWID’s sexual network was limited. Caution would still be needed though
since condom use has been low (36.6% during the last sex) and inconsistent (17.7% consistency
in the last month).

Unprotected sex among PWID was influenced by marital status, methamphetamine use and sex
under the influence of substance or alcohol (Abdala et al., 2010). In this survey, cross-tabulation
could only be done on the variable of marital status and the result showed that condom use and
consistency in condom use was lower among married PWID compared to that in unmarried
PWID. The most logical explanation for this was because married PWID trusted their partner, as
reported by Pines et al. (2016).

7.4.2.2 Commercial Partner

The proportion of PWID who engaged in commercial sex and used condom during paid sex is
presented in the Table below.

Table 7.17 PWID’s Sexual Behavior and Condom Use with Commercial Sex Partner

Buy Sex Sell Sex

District/Municipality n* Use condom Use condom
Yes Used condom in last Yes Used condom in last
consistently** consistently
(%) sex (%) (%) sex (%)
(%) (%)
Banda Aceh City# 11 27.3 33.3 33.3 18.2 50.0 50.0
Padang City# 48 27.1 23.1 12.5 2.1 0.0 0.0
Bandar Lampung City# 51 19.6 60.0 50.0 3.9 50.0 50.0

East Jakarta City 172 12.8 45.5 25.0 4.1 42.9 50.0
Bogor 184 16.3 10.0 0.0 2.2 25.0 0.0
Sukabumi 211 5.2 54.5 37.5 2.4 60.0 40.0
West Bandung 213 25.4 40.7 53.3 0.0 NA NA

Sukabumi City 209 18.2 47.4 16.0 1.0 100.0 100.0

Bandung City 196 12.2 70.8 45.5 1.5 66.7 NA
Bekasi City 201 10.0 50.0 38.5 0.0 NA NA
Depok City 194 15.5 63.3 58.3 4.6 55.6 25.0

Salatiga City 100 14.0 64.3 37.5 0.0 NA NA

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 Buy Sex Sell Sex
District/Municipality n* Use condom Use condom
Yes Used condom in last Yes Used condom in last
consistently** consistently
(%) sex (%) (%) sex (%)
(%) (%)
Yogyakarta City# 15 0.0 NA NA 0.0 NA NA

Kota Tangerang# 36 33.3 66.7 50.0 2.8 100.0 100.0

Tangerang Selatan City# 43 16.3 42.9 NA 0.0 NA NA
Badung# 82 22.0 88.9 50.0 8.5 71.4 66.7
Kupang City# 4 25.0 100.0 NA 0.0 NA NA

Makassar City 205 9.3 52.6 28.6 2.9 50.0 66.7

Aggregate 1885 13.9 47.3 35.5 1.9 51.4 43.8

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who have had sex; **Among respondents who had sex in the last month; NA: not applicable.

More than one of every eight PWID respondents buy sex and almost all of them were male
(99.2%). Condom in the last paid sex was used by only 47.3% of respondents, and condom use
consistency in the last month was only 35.5%. As shown in the table, condom use in the last sex
among PWID in Bogor was very low (10%) and none of the respondents consistently used
condom. Female PWID typically enter the sex industry due to poverty, unemployment, low
education, and the need to provide for herself and/or her partner (National Drug and Alcohol
Research Centre, 2010).

In the last sex, 51.4% of PWID used condom, and 43.8% used condom consistently. Female PWID
were more consistent in using condom than male PWID (66.7% vs. 38.5%), which was quite
surprising since a review by the National Drug and Alcohol Research Centre (2010) reported that
female PWID usually had a lower bargaining position during sexual transaction as they typically
sold sex as a way to make ends meet.

7.5 STI Symptom, Testing and Treatment

7.5.1 STI Symptom and Testing

STI symptoms that are presented here are a composite of eight STI symptoms that were asked to
respondents. These consisted of pain during urination, genital wart, anal wart, sore/ulcer in the
genital area, sore/ulcer in the anal area, abnormal discharge from the vagina/penis, abnormal
discharge from the anus and lump/swelling around the anus. Respondents with any one of the
symptoms are categorized as having a symptom. Other variables presented in this section
included STI testing, location of test, and STI test in the last year.

Table 7.18 PWID’s STI Symptom, Testing and Location of Last STI Test
Had STI Location of Last STI Test (%) Had STI Test
Had STI Test
District / Municipality n Symptom n* Private NGO Mobile in the Last 6
(%) Puskesmas Hospital Other
(%) Clinic Clinic STI Months
Banda Aceh City# 15 26.7 13.3 2 50.0 50.0 0.0 0.0 0.0 0.0 50.0
Padang City# 76 1.3 7.9 6 83.3 0.0 0.0 0.0 16.7 0.0 50.0

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 Had STI Location of Last STI Test (%) Had STI Test
Had STI Test
District / Municipality n Symptom n* Private NGO Mobile in the Last 6
(%) Puskesmas Hospital Other
(%) Clinic Clinic STI Months
Bandar Lampung City# 57 5.3 5.3 3 33.3 33.3 0.0 0.0 0.0 33.3 66.7

East Jakarta City 180 4.4 15.6 28 46.4 17.9 7.1 3.6 25.0 0.0 46.4
Bogor 219 9.1 7.8 17 47.1 29.4 0.0 0.0 23.5 0.0 64.7
Sukabumi 220 6.4 6.4 14 92.9 0.0 0.0 7.1 0.0 0.0 14.3
West Bandung 220 3.2 6.8 15 80.0 6.7 6.7 0.0 6.7 0.0 66.7

Sukabumi City 214 4.2 11.2 24 75.0 8.3 4.2 4.2 0.0 8.3 8.3
Bandung City 219 11.4 8.2 18 61.1 16.7 16.7 5.6 0.0 0.0 44.4

Bekasi City 215 2.3 9.8 21 90.5 4.8 4.8 0.0 0.0 0.0 95.2
Depok City 218 7.8 6.9 15 80.0 0.0 13.3 0.0 6.7 0.0 53.3

Salatiga City 104 14.4 21.2 22 95.5 4.5 0.0 0.0 0.0 0.0 77.3
Yogyakarta City# 16 0.0 12.5 2 50.0 0.0 50.0 0.0 0.0 0.0 50.0

Kota Tangerang# 36 13.9 38.9 14 85.7 7.1 0.0 7.1 0.0 0.0 64.3
Tangerang Selatan City# 43 20.9 9.3 4 75.0 25.0 0.0 0.0 0.0 0.0 50.0
Badung# 84 11.9 20.2 17 58.8 17.6 17.6 5.9 0.0 0.0 52.9
Kupang City# 4 25.0 25.0 1 100.0 0.0 0.0 0.0 0.0 0.0 0.0
Makassar City 220 2.3 3.2 7 42.9 28.6 0.0 14.3 0.0 14.3 42.9
Aggregate 2029 6.2 8.9 181 71.8 11.0 5.5 2.8 7.2 1.7 37.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Number of
respondents who had STI test

Overall 6.2% of PWID had at least one STI symptom. The most common symptom was pain during
urination (4.8%) and abnormal vaginal/penile discharge (2.1%). These were two symptoms that
are quite specific for Gonorrhea and Chlamydia. PWID are at risk of STI, specifically acute
infections like Gonorrhea and Chlamydia due to the low condom use in their last sex.

Irrespective of the symptom, 8.9% of PWID had STI test, and 37% of them had the test in the last
year. The most common health facility PWID went to was Puskesmas (71.8%) followed by
Hospital (11.0%). STI test is part of the government program so STI test in public health facilities
is provided free of charge.

7.5.2 STI Treatment

Table 7.19 below presents data on the treatment that respondents received when they
experienced STI symptoms, along with the location of treatment to identify any preference with
regards to treatment location. The last variable that was asked to respondents was whether they
suggested their partner to also be tested for STI.

Table 7.19 STI Treatment, Place of Treatment and STI Test Recommendation to Partner
Went to a health Location of STI Treatment* (%) Recommend
provider when
STI Test to
District / Municipality n* experienced STI Private
Puskesmas Hospital NGO Clinic Mobile STI Other Partner**
symptoms*
Clinic (%)
(%)
Banda Aceh City# 2 0.0 50.0 50.0 0.0 0.0 0.0 0.0 50.0
Padang City# 6 33.3 83.3 0.0 0.0 0.0 16.7 0.0 100.0

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 Went to a health Location of STI Treatment* (%) Recommend
provider when
STI Test to
District / Municipality n* experienced STI Private
Puskesmas Hospital NGO Clinic Mobile STI Other Partner**
symptoms*
Clinic (%)
(%)
Bandar Lampung City# 3 100.0 33.3 33.3 0.0 0.0 0.0 33.3 50.0

East Jakarta City 28 21.4 46.4 17.9 7.1 3.6 25.0 0.0 75.0
Bogor 17 29.4 47.1 29.4 0.0 0.0 23.5 0.0 60.0

Sukabumi 14 57.1 92.9 0.0 0.0 7.1 0.0 0.0 0.0

West Bandung 15 20.0 80.0 6.7 6.7 0.0 6.7 0.0 44.4
Sukabumi City 24 45.8 75.0 8.3 4.2 4.2 0.0 8.3 25.0
Bandung City 18 55.6 61.1 16.7 16.7 5.6 0.0 0.0 57.1

Bekasi City 21 47.6 90.5 4.8 4.8 0.0 0.0 0.0 20.0
Depok City 15 33.3 80.0 0.0 13.3 0.0 6.7 0.0 0.0

Salatiga City 22 13.6 95.5 4.5 0.0 0.0 0.0 0.0 100.0
Yogyakarta City# 2 50.0 50.0 0.0 50.0 0.0 0.0 0.0 66.7

Kota Tangerang# 14 21.4 85.7 7.1 0.0 7.1 0.0 0.0 100.0
Tangerang Selatan City# 4 50.0 75.0 25.0 0.0 0.0 0.0 0.0 100.0

Badung# 17 17.6 58.8 17.6 17.6 5.9 0.0 0.0 NA

Kupang City# 1 0.0 100.0 0.0 0.0 0.0 0.0 0.0 25.0

Makassar City 7 57.1 42.9 28.6 0.0 14.3 0.0 14.3 50.0

Aggregate 181 35.9 71.1 11.0 5.5 2.8 7.2 1.7 38.0
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples: *Number of
respondents who had STI test; **Among respondents who went to a health provider upon experiencing STI symptoms.

Among respondents who experienced one STI symptom, only 35.9% sought treatment from a
health provider. This was quite a high proportion since most respondents chose to ignore the
symptom or self-treat. This was also the reason why only a small proportion of respondents
recommended their partners to get STI test as well.

Two common health facilities respondents went to were Puskesmas (71.1%) and Hospital
(11.0%). This was thought to relate to efficiency. By getting tested at a Puskesmas or Hospital,
any treatment required could also be obtained directly from the same facility.

7.6 HIV Test and Treatment

Data on HIV program coverage is presented as a continuum of care starting from testing to receipt
of result and treatment. The HIV/AIDS program cascade starts with participation in HIV test,
receipt of result, knowing the result, ARV therapy and follow-on test in the form of viral load to
evaluate treatment effectiveness.

7.6.1 HIV Test and Test Location

Table 7.20 below presents information about HIV testing and the location of testing, also the
proportion of PWID who had HIV test in the last year. The data was obtained from a recoding of
the question on the number of HIV test that respondents had in the last year. Answers of 00 and

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 more than five times were categorized as not having HIV test in the last year, while answers of 1-
5 times were categorized as having HIV test in the last year.

Table 7.20 HIV Testing and Location of Last HIV Test

HIV Test Location of Last HIV Test* HIV Test
Yes, on own in the
District /
n Yes, on own Yes, based on initiative and n Private NGO Mobile last 1
Municipality Never Puskesmas Hospital Other
initiative referral based on Clinic Clinic VCT year*
referral (%)
Banda Aceh
15 6.7 6.7 6.7 80.0 3 33.3 66.7 0.0 0.0 0.0 0.0 66.7
City#
Padang City# 76 7.9 7.9 0.0 84.2 12 75.0 0.0 0.0 0.0 16.7 8.3 75.0
Bandar
57 42.1 12.3 14.0 31.6 39 51.3 43.6 0.0 0.0 2.6 2.6 89.7
Lampung City#
East Jakarta
180 19.4 38.3 32.2 10.0 162 46.9 10.5 2.5 12.3 22.2 5.6 71.0
City
Bogor 219 13.2 20.5 44.7 21.5 172 54.7 12.2 1.2 4.7 27.3 0.0 77.9
Sukabumi 220 16.4 2.7 35.5 45.5 120 53.3 0.0 0.8 25.8 20.0 0.0 91.7
West Bandung 220 8.2 10.0 57.3 24.5 166 65.7 3.6 0.6 1.2 28.9 0.0 91.0
Sukabumi City 214 40.7 15.0 9.3 35.0 139 87.8 3.6 0.0 3.6 2.9 2.2 92.8
Bandung City 219 17.4 18.3 44.7 196 176 51.7 2.8 1.1 22.7 14.8 1.1 90.3
Bekasi City 215 60.9 0.9 9.3 28.8 153 79.1 8.5 2.0 3.3 5.2 2.0 84.3
Depok City 218 20.2 7.8 26.6 45.4 119 52.1 5.9 0.8 24.4 16.0 0.8 84.9
Salatiga City 104 24.0 16.3 12.5 47.1 55 81.8 9.1 0.0 5.5 3.6 0.0 81.8
Yogyakarta
16 37.5 12.5 50.0 0.0 16 75.0 6.3 0.0 0.0 18.8 0.0 93.8
City#
Kota
36 50.0 19.4 22.2 8.3 33 3.0 36.4 3.0 3.0 0.0 3.0 69.7
Tangerang#
Tangerang
43 32.6 16.3 14.0 37.2 27 44.4 25.9 7.4 7.4 11.1 3.7 85.2
Selatan City#
Badung# 84 40.5 7.1 22.6 29.8 59 72.9 11.9 6.8 6.8 1.7 0.0 74.6
Kupang City# 4 25.0 0.0 50.0 25.0 3 0.0 100.0 0.0 0.0 0.0 0.0 66.7
Makassar City 220 5.0 11.4 30.9 52.7 104 60.6 15.4 5.8 16.3 1.0 1.0 50.0
Aggregate 2029 22.4 13.6 31.4 32.7 1366 62.0 7.0 1.5 11.7 16.5 1.4 82.5
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who have had HIV test;

As an aggregate 67.3% of PWID have had HIV tests, 22.4% were tested on their own initiative,
13.6% were referred while 31.4% were tested both based on their own initiative and referral.
Among those who were tested, 82.5% had the test in the last year. This showed that in addition
to good self awareness about HIV, for PWID to get tested, there also needs to be persuasion and
recommendation from a health provider. This was evidenced in the proportion of HIV test in the
last year that was higher among respondents who met/discussed with a service provider (86.2%)
compared to respondents who did not meet any service provider in the last year (77.6%) (PORc
1.8; 95%CI 1.4-2.4). A similar finding was reported from a study by Ganju, Ramesh and Saggurti
(2016).

In the last HIV test, the health facility of choice for PWID was Puskesmas (62.0%). In some sites,
more than 80% of HIV test was performed in Puskesmas, for example in Sukabumi City (87.8%),
and Salatiga City (81.8%). The second most common testing location was mobile VCT service

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 (16.5%), an HIV-testing service outside a health facility that Puskesmas provides to target
population. This showed that the mobile service program was already able to identify places
where PWID gather in each area.
One advantage of mobile VCT service is that it enables PWID to get HIV test with more privacy.

7.6.2 Reason for Getting and Not Getting HIV Test

About 67.3% of PWID respondents has had HIV test, so there was still 32.7% of PWID respondents
who needed encouragement to be more aware of the risk and get tested. For this to happen,
reasons why PWID decided to get tested or not get tested needed to be identified so that suitable
interventions could be implemented appropriately.

Table 7.21 PWID’s Reason for Getting and Not Getting HIV Test
Reasons for Getting HIV Test*,^(%) Reasons for Not Getting HIV Test **,^(%)

District/ Recomm. Recomm. by Recomm. by Do not Do not Do not

n Feel by a a field/ a friend/ n Test site want to know know
Municipality Feel Sick Other Expensive Other
At Risk health outreach partner/ far away know testing need
provider worker family status site HIV test
Banda Aceh
3 66.7 0.0 0.0 0.0 0.0 33.3 5 0.0 20.0 60.0 20.0 0.0 0.0
City#
Padang City# 12 33.3 0.0 16.7 25.0 16.7 8.3 23 0.0 0.0 21.7 4.3 69.6 4.3
Bandar
39 64.1 10.3 10.3 5.1 7.7 2.6 9 0.0 0.0 33.3 11.1 55.6 0.0
Lampung City#
East Jakarta
162 71.6 1.2 9.9 14.2 1.2 1.9 13 0.0 0.0 23.1 23.1 38.5 15.4
City
Bogor 172 42.4 13.4 11.0 29.7 1.2 2.3 23 17.4 0.0 43.5 21.7 17.4 0.0
Sukabumi 120 15.0 0.0 7.5 74.2 3.3 0.0 35 0.0 0.0 14.3 17.1 68.6 0.0
West Bandung 166 21.7 0.0 7.2 68.1 1.8 1.2 36 5.6 0.0 58.3 13.9 13.9 8.3
Sukabumi City 139 75.5 2.2 12.2 6.5 3.6 0.0 20 0.0 5.0 70.0 10.0 15.0 0.0
Bandung City 176 73.9 1.1 3.4 11.4 3.4 6.8 31 3.2 3.2 3.2 19.4 32.3 38.7
Bekasi City 153 66.0 1.3 16.3 5.2 5.2 5.9 21 4.8 0.0 23.8 4.8 42.9 23.8
Depok City 119 47.9 0.8 16.0 27.7 2.5 5.0 69 0.0 1.4 44.9 20.3 31.9 1.4
Salatiga City 55 5.5 0.0 38.2 49.1 0.0 7.3 21 0.0 0.0 4.8 0.0 95.2 0.0
Yogyakarta
16 62.5 0.0 18.8 18.8 0.0 0.0 0
City#
Tangerang
33 72.7 12.1 3.0 6.1 3.0 3.0 1 0.0 0.0 0.0 0.0 0.0 100.0
City#
Tangerang
27 37.0 11.1 33.3 0.0 7.4 11.1 8 0.0 0.0 12.5 37.5 50.0 0.0
Selatan City#
Badung# 59 45.8 0.0 10.2 23.7 5.1 15.3 12 0.0 0.0 25.0 25.0 8.3 25.0
Kupang City# 3 66.7 0.0 0.0 0.0 33.3 0.0 1 0.0 0.0 100.0 0.0 0.0 0.0
Makassar City 104 63.5 5.8 4.8 22.1 1.9 1.9 46 2.2 0.0 4.3 15.2 65.2 13.0
Aggregate* 1366 2.9 51.6 10.9 29.0 2.6 3.1 663 2.9 1.0 29.5 15.6 41.9 9.2
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

Half of PWID respondents acknowledged that they had HIV test because they felt at risk (51.6%).
This indicated that a perception of risk drove respondents to get tested. This risk perception could
be increased through meeting and discussion with health worker/field outreach worker or
through educational media. Another reason for getting HIV test was recommendations from a

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 field/outreach worker (29.0%). This finding showed that field outreach workers have an
important role in getting respondents to get HIV test.

Respondents who had never got tested cited lack of knowledge as their primary reason (41.9%).
They did not know that they needed to get tested. This related to level of HIV knowledge. Indeed,
78.1% of respondents with comprehensive HIV knowledge had got tested, while among
respondents with no comprehensive knowledge only 52,8% got HIV test. The next reason for not
getting tested was because respondents did not wish to know their HIV status (29.5%) and
another 15.6% of respondents did not know which facility provided the service. Those were three
top reasons for not getting tested and all of them were personal reasons that were quite
subjective. Only about 3.9% of respondents cited reasons that related to access like the location
of test that was far (2.9%) and concern about the cost of test (1%). It can be concluded that the
infrastructure for providing HIV testing service was already good. The remaining task would be
to improve the knowledge and awareness of high-risk groups, including PWID.

7.6.3 Consent, Counseling and Receipt of HIV Test Result

Before an individual receives HIV test, some ethical aspects have to be fulfilled, i.e. they have to
consent to a blood draw, and receive counseling before receiving their results. Then a health
provider will give the test result to the individual. The table below presents information on
receipt of HIV test result in under 2 hours. The timing of two hours was set as the maximum time
a person would be willing to wait. An individual who needs to wait for longer than two hours may
decide to go home, and then will need to spend additional time, energy and cost to return to the
health facility. This increases the likelihood of the respective person not picking up their test
result, hence not knowing their HIV status.

Table 7.22 Consent, Counseling and Receipt of HIV Test Result among PWID
For respondents who had HIV test Received test Recommend HIV
Consent for blood Received counseling Received the test result in less than Test to Steady
District/Municipality n
draw was obtained before getting the result result 2 hours* Partner**
(%) (%) (%) (%) (%)
Banda Aceh City# 3 100.0 100.0 100.0 33.3 13.3
Padang City# 12 100.0 100.0 100.0 58.3 11.8
Bandar Lampung City# 39 100.0 100.0 100.0 79.5 36.8
East Jakarta City 162 95.7 93.2 97.5 55.1 43.9
Bogor 172 88.4 87.2 59.3 32.4 14.6
Sukabumi 120 96.7 93.3 88.3 90.6 25.0
West Bandung 166 100.0 98.2 64.5 44.9 7.3
Sukabumi City 139 100.0 100.0 91.4 84.3 17.8
Bandung City 176 98.9 98.3 94.3 86.1 23.3
Bekasi City 153 98.7 98.0 95.4 76.7 18.6
Depok City 119 99.2 98.3 97.5 89.7 28.4
Salatiga City 55 100.0 98.2 61.8 11.8 19.2
Yogyakarta City# 16 100.0 100.0 93.8 100.0 50.0

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 For respondents who had HIV test Received test Recommend HIV
Consent for blood Received counseling Received the test result in less than Test to Steady
District/Municipality n
draw was obtained before getting the result result 2 hours* Partner**
(%) (%) (%) (%) (%)
Kota Tangerang# 33 90.9 100.0 100.0 72.7 66.7
Kota Tangerang
27 88.9 81.5 88.9 16.7 44.2
Selatan#
Badung# 59 100.0 96.6 96.6 80.7 46.4
Kupang City# 3 100.0 100.0 100.0 66.7 50.0
Makassar City 104 99.0 97.1 95.2 70.7 19.1

Aggregate* 1366 97.3 95.9 85.0 69.3 21.4

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who received the result of their last HIV test; **Among all respondents.

Almost all PWID respondents had HIV test after consenting to the blood draw (97.2%). In some
Districts/Municipalities, the percentage was even 100% (West Bandung District, Sukabumi City
and Salatiga City). Based on the Minister of Health Regulation No.74/2014 on HIV Counseling and
Testing Guideline, consent could be obtained in writing or verbally.

Following the test, 95.9% of respondents reported that they received counseling before receiving
their test result. The objective of counseling is to prepare clients for the test result. During
counseling clients were provided with an explanation about all the details of the test result, what
to do if the result was positive, or negative, and all the consequences.

Not all PWID respondents received their HIV test result. Only 85% did. Those who did not receive
their result then did not get confirmation about their HIV status, which if positive would be very
dangerous as without knowing that they had been infected, the respective individuals may not be
making any effort to prevent transmission.

Length of time between testing and receipt of test result became important to increase the
coverage of test result receipt. Table 7.22 above shows that 69.3% of respondents received their
test result in 2 hours, which was quite fast. This may need to be improved further to meet the
target of less than 2 hours as stated in the Minister of Health Regulation No.74/2014 on HIV
Counseling and Testing Guideline.

Among respondents who received HIV test, only 21.4% recommended their partners to get tested,
while 52.4% of those respondents were ones who did not use condom consistently.

7.6.4 HIV Treatment and Viral Load Test among PWID

In the final part of HIV care cascade, data that are needed are data on testing and identification of
test result, followed with data on ARV therapy and evaluation of treatment using viral load test.

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 Table 7.23 HIV Treatment and Viral Load Test among PWID
Are still Stopped taking
Receive CST Viral Load Had Viral Load Received
District / Service1 Receive ARV2 taking ARV ARV for 3
n1 Test2 Test in the last Viral Load
Municipality (%) (%) until now3 months 4
(%) 12 months5 (%) Test Result5
(%) (%)
Banda Aceh City#

Padang City# 1 0.0

Bandar
14 100.0 100.0 100.0 14.3 92.9 92.3 100.0
Lampung City #
East Jakarta City 70 94.3 100.0 92.4 27.9 74.2 65.3 95.9
Bogor 12 58.3 71.4 60.0 66.7 42.9 66.7 100.0
Sukabumi 1 100.0 100.0 100.0 0.0 0.0
West Bandung 4 100.0 100.0 100.0 0.0 50.0 0.0 100.0
Sukabumi City 20 85.0 100.0 94.1 12.5 52.9 11.1 100.0
Bandung City 9 77.8 100.0 85.7 16.7 71.4 60.0 80.0
Bekasi City 21 71.4 100.0 93.3 21.4 80.0 41.7 100.0
Depok City 14 92.9 92.3 100.0 75.0 53.8 85.7 100.0
Salatiga City 5 100.0 100.0 100.0 0.0 100.0 100.0 100.0
Yogyakarta City# 4 100.0 100.0 100.0 25.0 75.0 66.7 100.0
Tangerang City # 24 70.8 100.0 100.0 5.9 52.9 22.2 77.8
South Tangerang
12 66.7 87.5 57.1 0.0 25.0 0.0 100.0
City#
Badung# 13 100.0 92.3 100.0 33.3 76.9 70.0 80.0
Kupang City# 1 100.0 100.0 100.0 0.0 100.0 100.0 100.0
Makassar City 43 97.7 100.0 97.6 39.0 40.5 58.8 70.6
Aggregate 199 88.9 98.3 92.1 30.7 61.6 58.7 92.7
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; 1Among
respondents with positive HIV test; 2Based on the number of respondents who receive CST; 3Based on the number of respondents
who receive ARV; 4Based on the number of respondents who are still taking ARV until now; 5Based on the number of respondents who
had viral load test;

After getting HIV test, 199 PWID respondents received a positive test result (based on
respondent’s statement in the behavioral questionnaire). Among these respondents, only 88.9%
received CST service, and 98.3% received ARV. Up to a month before the interview, 92.1% of
respondents who had received ARV were still taking ARV. Unfortunately, among those who were
still taking ARV at the time of the interview, 30.7% stopped taking ARV for three months in the
past.

Viral Load test is a test to measure the number of viral particles in the blood, and is commonly
performed around eight weeks after an individual initiates ARV therapy. The purpose is to
evaluate therapy efficacy. Among PWID respondents who received CST service, only 61.6%
received viral load test. One reason for the low percentage of viral load test was because the test
was still quite costly. Global Fund provided assistance for viral load testing but the amount was
limited. In the last year, only 58.7% respondents received viral load test, and 92.7% of them
received the result.

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 7.7 TUBERCULOSIS (TB)
TB is the most commonly reported co-infection of HIV so implementation of TB program should
be integrated with the HIV program in order to be comprehensive. This section presents data on
the number of PWID respondents who experienced TB symptoms, were tested for TB, received
treatment and were offered HIV test while getting TB service.

Table 7.24 TB Symptom, Testing, Treatment and Offer of HIV Test

Those who received TB test
Had coughs for >2 Had been tested
Received TB Offered HIV Test
District / Municipality n weeks in the last 1 for TB Know the TB Test
Treatment Package during TB Service
year (%) (%) Result (%)
(%) (%)
Banda Aceh City# 15 20.0 13.3 100 0.0 50.0
Padang City# 76 1.3 1.3 100.0 100.0 100.0
Bandar Lampung City# 57 15.8 15.8 100.0 55.6 77.8
East Jakarta City 180 11.1 20.0 100.0 44.4 27.8
Bogor 219 15.5 4.6 60.0 30.0 90.0
Sukabumi 220 6.8 5.5 100.0 91.7 91.7
West Bandung 220 10.9 4.1 88.9 22.2 55.6
Sukabumi City 214 7.9 10.7 82.6 26.1 56.5
Bandung City 219 11.4 11.0 87.5 25.0 50.0
Bekasi City 215 10.2 17.7 100.0 34.2 68.4
Depok City 218 9.2 10.1 95.5 40.9 50.0
Salatiga City 104 5.8 8.7 100.0 0.0 88.9
Yogyakarta City# 16 12.5 43.8 100.0 42.9 28.6
Kota Tangerang# 36 25.0 44.4 100.0 56.3 68.8
Tangerang Selatan City# 43 25.6 30.2 92.3 38.5 53.8
Badung# 84 15.5 14.3 100.0 33.3 41.7
Kupang City# 4 25.0 0.0
Makassar City 220 12.3 14.1 96.8 51.6 22.6

Aggregate 2029 10.3 10.5 93.5 38.3 52.3

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

One of every ten PWID reported having coughs for more than two weeks in the last year, and a
similar number of PWID said they had TB test. Almost all of them received the test results, and
38.3% received treatment, which was assumed to be the number of respondents who were
diagnosed with TB. In general, the number of TB can roughly be estimated as follows: 38.3% x
10.5% (respondents who got tested), which is 4% of all PWID respondents.
During TB testing, only 52.3% of respondents stated that they were offered to get HIV test. The
Decree of the Minister of Health Number 1278/MENKES/SK/XII/2009 on The Implementation
Guideline for TB and HIV Integrated Intervention states that in areas with a low and concentrated
HIV epidemic, HIV testing is performed on TB patients with the following risk factors: PWID, sex
workers, people with multiple partners, people with history of STI, people in high-risk occupation
and people with history of blood or blood product transfusion. In areas with generalized HIV
epidemic, then HIV test is performed on all TB patients in the routine DOTS unit (UPK). In Table

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 7.24 above it could be seen that HIV test was offered more to respondents who received TB test
than to respondents who were diagnosed and were receiving TB treatment. So the Decree was
already well implemented by offering HIV test to TB patients of high-risk group, which in this case
was PWID.

The survey also tried to estimate the TB-HIV co-infection. About 47.5% of PWID respondents had
both TB and HIV. According to Meijerink et al. (2015) HIV infection significantly contributes to
the incidence of TB among PWID, compounded with the fact that PWID had a low rate of health
care utilization, and low adherence to treatment. The percentage of PWID who completed TB
treatment was also low, which further increased the severity of TB and caused widespread
transmission among PWID (Meijerink et al., 2015).

7.8 Hepatitis
This section presents results about testing and treatment of Hepatitis B and C. The variable of
ever been tested for Hepatitis was presented to obtain a picture of all the respondents, so the
denominator in this variable was all the respondents. The variable of knowing the Hepatitis B and
C test result was a variable that was recoded from the variable of Hepatitis test result.
Respondents who stated their result as positive or negative would be categorized as knowing
their test result, while respondents who said they didn’t know their test result would be
categorized as not knowing their test result. This variable would only illustrate the result among
respondents who ever had Hepatitis test. For Hepatitis B there was also a specific question on
immunization to gain insight about any preventive action that respondents had done. For
Hepatitis C data presented also included information about Hepatitis C treatment that
respondents with Hepatitis C positive result received.

Table 7.25 Hepatitis Testing, Prevention and Treatment

Hepatitis B Hepatitis C
Had Know the Hep B Had Know the Receive Hep C
District / Municipality n
Hep B Test Hep B Test Immunization* Hep C Test Hep C Test Treatment**
(%) Result* (%) (%) (%) Result* (%) (%)
Banda Aceh City# 15 20.0 100.0 0.0 20.0 100.0 100.0
Padang City# 76 0.0 1.3 100.0 100.0
Bandar Lampung City# 57 15.8 100.0 66.7 29.8 100.0 57.1

East Jakarta City 180 9.4 88.2 47.1 52.2 95.7 41.8
Bogor 219 9.6 61.9 28.6 8.2 66.7 20.0

Sukabumi 220 5.5 100.0 75.0 2.3 100.0 100.0

West Bandung 220 3.2 100.0 42.9 10.9 50.0 25.0

Sukabumi City 214 8.9 94.7 36.8 9.8 90.5 76.9

Bandung City 219 4.1 88.9 44.4 7.3 87.5 66.7

Bekasi City 215 15.8 85.3 35.3 13.5 86.2 36.4

Depok City 218 6.9 100.0 60.0 3.2 100.0 66.7

Salatiga City 104 8.7 100.0 33.3 6.7 100.0 33.3

213
 Hepatitis B Hepatitis C
Had Know the Hep B Had Know the Receive Hep C
District / Municipality n
Hep B Test Hep B Test Immunization* Hep C Test Hep C Test Treatment**
(%) Result* (%) (%) (%) Result* (%) (%)
Yogyakarta City# 16 31.3 100.0 60.0 50.0 100.0 50.0

Kota Tangerang# 36 25.0 88.9 66.7 38.9 85.7 72.7

Tangerang Selatan City# 43 23.3 90.0 50.0 25.6 90.9 33.3

Badung# 84 17.9 100.0 46.7 26.2 86.4 45.5

Kupang City# 4 25.0 100.0 0.0 0.0

Makassar City 220 6.8 100.0 46.7 22.3 91.8 23.8

Aggregate 2029 7.8 89.2 43.0 13.3 87.4 43.9

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; *Among
respondents who have had Hepatitis test; **Among respondents with positive Hep C test result.

About 7.8% of PWID respondents were tested for Hepatitis B, lower than the proportion of
respondents who were tested for Hepatitis C (13.3%). This showed that respondents had higher
awareness about Hepatitis C than about Hepatitis B. A systematic review showed that the
prevalence of Hepatitis C among PWID was higher than the prevalence of Hepatitis B or even HIV
(Nelson et al., 2011). The study also reported that the health and financial impact of Hepatitis C
on PWID was actually worse than the consequence they endured as a result of HIV.

Among PWID who had Hepatitis test, more than 87% knew their test result. Based on
respondents’ statement, 19.0% were Hepatitis B positive, and 51.5% were Hepatitis C positive.
Hepatitis B immunization was only received by 43.0% of respondents who were tested.

Among PWID with positive Hepatitis C test, only 43.9% received treatment. A number of factors
played a role for this low percentage, ranging from service access, cost, etc. The latest treatment
for Hepatitis C, Direct-Acting Antiviral (DAA), has been incorporated into the Ministry of Health
program, and was introduced in 2017.

7.9 Coverage of Other Prevention Program

The HIV program includes several prevention interventions that are commonly implemented as
meetings or information dissemination through IEC media. To get information about the coverage
of such programs, all the respondents were used as the denominator.

Table 7.26 Coverage of Other HIV Prevention Program among PWID

Attend meeting/discuss Receive printed/ Receive free condom Contacted by

District / Municipality n with health worker audio-visual materials From field outreach field outreach
(%) on HIV (%) worker (%) worker (%)

Banda Aceh City# 15 20.0 6.7 14.3 13.3

Padang City# 76 5.3 11.8 26.3 5.3

Bandar Lampung City# 57 36.8 43.9 29.3 24.6

214
 Attend meeting/discuss Receive printed/ Receive free condom Contacted by
District / Municipality n with health worker audio-visual materials From field outreach field outreach
(%) on HIV (%) worker (%) worker (%)

East Jakarta City 180 46.1 41.7 39.8 28.3

Bogor 219 38.4 51.1 23.9 20.1

Sukabumi 220 38.2 50.9 49.2 44.1

West Bandung 220 65.0 58.6 13.6 36.4

Sukabumi City 214 22.0 10.7 27.0 16.8

Bandung City 219 60.3 40.6 18.7 46.1

Bekasi City 215 45.6 56.3 20.9 22.3

Depok City 218 34.4 45.4 21.1 20.2

Salatiga City 104 45.2 42.3 18.6 8.7

Yogyakarta City# 16 87.5 56.3 25.0 31.3

Kota Tangerang# 36 88.9 52.8 65.7 52.8

Tangerang Selatan
43 32.6 34.9 13.6 7.0
City#
Badung# 84 75.0 61.9 43.1 61.9
Kupang City# 4 25.0 50.0 33.3 25.0

Makassar City 220 34.1 23.2 34.9 27.7

Aggregate 2029 42.8 42.1 21.7 28.1
#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples

The coverage of all four HIV prevention activities among PWID was below 50%. The only activity
that provided PWID with the highest exposure to prevention activities was meetings/discussion
session about HIV with a health worker (42.8%). These discussion meetings were held with the
objective to improve knowledge. Cross-tabulation between meeting/discussion with health
worker and level of comprehensive knowledge showed those meetings to be quite effective.
Respondents who attended those meetings/discussions had higher level of comprehensive
knowledge (70.1%) relative to respondents who did not attend meetings (47.9% comprehensive
knowledge).

Another prevention activity included dissemination of printed/audio-visual materials about HIV

prevention and transmission. About 42.1% of respondents reported receiving those materials.
This is actually a one-way educational method but for sensitive issues such as HIV and substance
abuse, this approach was equally effective as face-to-face education/direct discussion. This was
evidenced in the proportion of comprehensive knowledge among those who received
printed/audio-visual material who was 69.4%, similar to those who had face-to-face meeting
(70.1%).

Provision of free condom is one effort to provide at-risk population access to condom and
increase their awareness to use condom during sex. About 21.7% of respondents received free
condom from a provider, at an average 2.8 condoms. A study once reported that respondents who
receive free condom would have higher adherence to use condom. This is similar to the result of
a cross-tabulation that showed 55.9% and 50.0% of condom use during last sex with a steady

215
 partner and non-steady partner respectively among respondents who received free condom. In
contrast, among respondents who did not receive free condom, only 25.6% and 29.4% used
condom with a steady and non-steady partner respectively.

To reach out to PWID and discuss HIV prevention and transmission, health workers and outreach
workers had been proactively contacting PWID. About 28.1% stated they had been contacted by
a worker in the last three months. A crude estimate showed that this proctive approach was able
to increase condom use consistency up to 1.4 times (POR 1,4; 95% CI 1,01-2,1).

During information dissemination to key populations, a field worker would need to present
information on HIV and STI prevention that is relevant for the respective key population. The
Table below presents the types of information that outreach workers conveyed to PWID.

Table 7.27 Types of Information PWID Received from Field Outreach Workers

Information that Respondents Receive from Field Outreach Workers (%)

District/ Peer
n Drug / TB Hepatitis Basic
Municipality HIV HIV Support CST for
Safe Transmiss Transmiss Condom NSEP Health MMT BMT STI
Transmission Testing Group PLHIV
Injection ion on Care
Activity
Banda Aceh
15 46.7 53.3 33.3 33.3 26.7 20.0 33.3 6.7 6.7 6.7 0.0 13.3 13.3
City#
Padang City# 76 11.8 11.8 6.6 3.9 9.2 6.6 14.5 2.6 2.6 0.0 0.0 2.6 1.3
Bandar
Lampung 57 45.6 56.1 31.6 29.8 38.6 31.6 29.8 14.0 17.5 35.1 3.5 12.3 15.8
City#
East Jakarta
180 35.6 54.4 33.9 28.3 31.7 16.1 28.3 5.6 0.0 5.6 2.2 2.2 5.6
City
Bogor 219 63.5 69.9 60.7 56.6 55.3 50.7 58.4 42.5 41.6 43.8 39.7 41.6 40.6

Sukabumi 220 59.5 64.5 30.5 17.7 60.5 54.5 23.2 4.1 3.6 8.2 2.3 6.8 0.0
West
220 30.5 75.5 23.2 19.5 60.5 18.2 32.7 3.6 3.2 6.8 0.5 2.3 2.3
Bandung
Sukabumi
214 32.2 35.0 27.1 25.7 30.8 26.2 27.1 15.4 13.1 6.1 1.4 16.4 3.3
City
Bandung City 219 57.1 70.3 39.3 25.6 59.4 28.8 55.3 13.2 11.4 12.3 13.2 9.1 4.1

Bekasi City 215 56.3 62.3 43.7 43.3 48.8 37.7 49.8 14.0 10.7 11.2 4.7 10.2 4.7

Depok City 218 35.8 39.9 11.5 7.3 31.7 20.6 38.5 6.9 5.0 13.3 17.4 7.3 3.7

Salatiga City 104 22.1 31.7 19.2 13.5 32.7 18.3 23.1 10.6 7.7 8.7 6.7 7.7 9.6
Yogyakarta
16 50.0 81.3 62.5 56.3 87.5 68.8 68.8 50.0 37.5 56.3 0.0 56.3 50.0
City#
Kota
36 83.3 88.9 77.8 69.4 86.1 77.8 83.3 58.3 58.3 30.6 8.3 50.0 36.1
Tangerang#
Tangerang
43 37.2 41.9 39.5 34.9 30.2 27.9 25.6 14.0 16.3 23.3 16.3 18.6 9.3
Selatan City#
Badung# 84 89.3 88.1 47.6 50.0 81.0 69.0 73.8 41.7 41.7 45.2 35.7 44.0 38.1

Kupang City# 4 50.0 75.0 25.0 25.0 50.0 50.0 50.0 25.0 50.0 50.0 25.0 25.0 25.0

Makassar City 220 40.9 42.3 27.3 28.6 35.5 30.0 48.2 21.4 20.9 18.2 4.5 17.3 13.2

Aggregate 2029 44.7 55.9 32.3 27.3 45.6 31.0 39.5 14.0 12.2 13.8 9.6 12.5 8.7

#These Districts/Municipalities were not included in the aggregate analysis due to their small number of samples; MMT= Methadone
Maintenance Treatment; BMT = Buprenorphine Maintenance Therapy

The above table shows that information about HIV transmission was the most common topic that
respondents received (55.9%) followed with information on safe injection practices (44.7%).

216
This latter topic should be emphasized further during meetings/discussion sessions with PWID
as a small proportion of PWID (1.5%) were still consistently using non-sterile (used) injection
devices and almost half of PWID still shared needles in the last month (41.4%) (see Table 7.10).

7.10 Positivity Rate of HIV, Syphilis and Hepatitis

Laboratory testing on the PWID group included four types of diseases: HIV, Syphilis, Hepatitis B
and C. All the PWID respondents provided samples for HIV and Syphilis test, while samples for
Hepatitis test were only collected in six selected Districts/Municipalities in West Java. The result
of the biological test among PWID is presented in Figure 7.1.

35 30.8
95% CI (28,5-33,1)
30

25

20
13.6
15 95% CI (12,2-15,2)

10
0.6 2.8
5 95% CI (2,1-3,7)
95% CI (0,3-1,1)

0
HIV Syphilis HEP B HEP C

Figure 7.1 Positivity Rate of HIV, Syphilis and Hepatitis in PWID

The above figure shows that Hepatitis C had the highest prevalence among PWID (30.8%). This is
due to PWID’s injection practice that directly exposed an individual to the Hepatitis C virus from
contaminated blood (Midgard et al., 2016). This survey also found that needle sharing in the last
month was a risk factor for Hepatitis C infection that was 1.4 times higher (95%CI 1.1-1.8). Needle
sharing practices among PWID was still high, at 41.4%.

For Hepatitis B, the prevalence aomng PWID was 2.8%. Shapatava, Nelson, Tsertsvadze, Del Rio,
C. (2006) reported that one source of Hepatitis B infection among PWID is unsafe cleaning
practices for injection. In the 2018-2019 IBBS, needle cleaning practice was only asked to
respondents who said they used non-sterile needle and the most common cleaning practice was
to clean the needle with boiling water (39.7%) or water (37.4%).

About 13.6% of PWID were also HIV positive. A number of studies had shown that PWID are at
high risk for HIV infection as a result of unsafe injection practices. A needle can contain HIV-

217
 infected blood for as long as 42 days (depending on temperature and other factors). Substance
abuse also increased the risk for sexual transmission of HIV. When an individual is under the
influence of substances, they tend to engage in high-risk sex such as anal or vaginal sex without
condom, sex with multiple partners and selling sex for money or drugs (CDC, 2019).

Syphilis prevalence was relatively low among PWID (0.6%). This indicated that PWID also
engaged in risky sexual behavior. Condom use consistency was only 22.4% with a steady partner
and even lower at 17.7% with a non-steady partner.

At the District/Municipality level, the distribution of HIV, Syphilis and Hepatitis prevalence is
listed in Table 7.28 below.

Table 7.28 Positivity Rate of HIV, Syphilis and Hepatitis among PWID in each District/Municipality

District / HIV Syphilis Hep B Hep C

Municipality n % n % % %
Banda Aceh City# 15 0.0 15 0.0
Padang City# 76 2.6 76 0.0
Bandar Lampung City# 57 29.8 57 0.0
East Jakarta City 180 43.9 180 2.8
Bogor 219 8.7 219 0.9 1.4 21.5
Sukabumi 220 1.8 220 0.0 5.5 2.3
West Bandung 220 3.6 220 0.0 2.3 51.4
Sukabumi City 213 16.0 213 0.0 5.2 25.8
Bandung City 219 2.7 219 1.4 0.9 72.0
Bekasi City 215 22.3 215 0.0 2.8 21.4
Depok City 218 11.5 218 1.4 1.8 21.6
Salatiga City 104 6.7 104 0.0
Yogyakarta City# 16 31.3 16 0.0
Kota Tangerang# 36 61.1 36 0.0
Tangerang Selatan City# 41 19.5 41 0.0
Badung# 78 17.9 78 1.3
Kupang City# 1 100.0 4 0.0
Makassar City 220 20.9 220 0.0
The highest proportion of HIV was in East Jakarta (43.9%). In some Districts/Municipalities such
as Tangerang City and Kupang City the proportion was 61.1% and 100% respectively but the
numbers were considered not representative for the respective District/Municipality as the
number of samples collected there was not sufficient. For Syphilis, as an aggregate, syphilis was
only found in three Districts/Municipalities, East Jakarta City (2.8%), Depok City (1.4%) and
Bandung City (1.4%).

The highest proportion of PWID respondents who were infected with Hepatitis B was found in
Sukabumi (5.5%) and Sukabumi City (5.2%). The highest proportion of Hepatitis C was in
Bandung City (72.0%) compared to the proportion in the other six Districts/Municipalities in
West Java.

218
 LIMITATION
The 2018-2019 IBBS had some limitations, one of which was about the number of samples in
several Districts/Municipalities that did not meet the target, for both the behavioral and
biological components of the survey. As a result, Districts/Municipalities with insufficient
number of samples were excluded from the aggregate analysis. They were: Simeulue District, East
Aceh District, Pamekasan District, Blitar City, and Mojokerto City for MSM, Aceh Besar District,
Mojokerto City, Madiun City, Kupang City, Palangkaraya City and Ambon City for waria, Simeulue
District, Bukittinggi City and Maluku Tenggara Barat District for FSWs, Bukittinggi City, Gianyar
District and Balikpapan City for clients, Banda Aceh City, Padang City, Bandar Lampung City,
Yogyakarta City, Tangerang Selatan City, Badung District and Kupang City for PWID.
Another limitation was also related to the different number of samples between the behavioral
component and the biological component of the survey, causing behavioral analysis to be done
on a different number of samples from positivity rate calculation. Behavioral analysis used the
number of respondents recruited for behavioral data, while positivity rates for HIV and Syphilis
were calculated using the number of samples collected for biological testing.

Data analysis in the 2018-2019 IBBS was unweighted since there was no information about the
number of clusters, key population clusters, or the population size in each selected cluster in the
District/Municipality. By not doing weighted analysis, it is possible that the results presented are
an over/underestimate. Unweighted analysis also caused the 2018-2019 IBBS result to only apply
on the respondents and cannot represent the national situation.

In the 2018-2019 IBBS, RDS analysis on the MSM and PWID groups could not be performed
because a lot of coupons or sheet were not completed.

219
 CONCLUSION AND
RECOMMENDATION
9.1 Conclusion
Based on data from the 2018-2019 IBBS several key findings could be concluded about the burden
of disease, knowledge and risk perception for HIV, protective behavior and exposure to
prevention program in each key population.

Men who have Sex with Men (MSM)

1. As an aggregate, the MSM group had quite a high burden of disease. The proportion of chronic
diseases like HIV and Syphilis was 17.9%, and 9.6% respectively. The proportion of acute
diseases of Chlamydia, Gonorrhea and Chlamydia-Gonorrhea mixed infection was even
higher, i.e. 27.1%, 17.8% and 12% respectively.
2. Only 40.4% of MSM respondents had comprehensive knowledge about HIV. This consisted
of knowledge that a healthy-looking person can be HIV-infected, that condom use and being
faithful to one’s partner can reduce the risk of HIV and that mosquito bite and food sharing
do not transmit HIV.
3. MSM had several types of sexual partner. Condom was more consistently used when
respondents had sex with a male non-steady partner (51.0%) or when they sold sex (51.0%).
During sex with a female partner, which was when MSM respondents sold sex, condom use
consistency was at the most only 31.1%.
4. Respondents’ exposure to HIV prevention program, both through face-to-face meeting, and
direct activities or through printed and audio-visual media was still very low. The highest
exposure to printed/audio-visual material was 33.5%. Free condom reached only 26.7% of
respondents. Active efforts by health/outreach field worker to reach out to each MSM
personally was reported by 24.5% of respondents, while direct face-to-face discussion with
health providers was reported by 23.9% of respondents.
5. The proportion of Hepatitis among MSM overall was quite low, i.e. 5.1% for Hepatitis B and
0.3% for Hepatitis C. About 21.6% of respondents had general knowledge about Hepatitis B.
Awareness about hepatitis and initiative to get tested was still very low. Only 5.9% of
respondents had Hepatitis B test, while for Hepatitis C test the proportion was even lower,
at 3.4% of respondents. Hepatitis B immunization was obtained by only 36.5% of
respondents.

220
Waria

1. The HIV positivity rate among waria as an aggregate was 11.9% CI (10.7-13.1). The positivity
rate of Syphilis was 9.9% CI (8.8-11.0), of Chlamydia was 13.9% CI (10.9-17.3), of Gonorrhea
was 8.6% CI (6.3-11.5) and of Chlamydia-Gonorrhea was 5.1% CI (3.3-7.5).
2. Level of comprehensive knowledge about HIV prevention and transmission among waria
was still quite low (40.9%). Risk perception among waria was 74.8% and the most commonly
known information about HIV prevention was condom use (87.8%).
3. Condom use during the last sex with waria’s steady partner and consistency in condom use
in the last month was 68.9% and 56.0% respectively. With non-steady partner, condom use
was 74.6% and 63.0% consistent. In commercial sex, among waria who bought sex from men
59.0% used condom in the last sex and 46.6% used condom consistently in the last month.
When waria sold sex, condom was consistently used 62.6% of the time.
4. HIV test coverage among waria was 72.0%. Most waria who have had HIV test, had their HIV
test ≤12 months ago (90.7%). The most common test location was Puskesmas (66.2%) and
mobile VCT service (22.0%). The majority of waria also received pre-test counseling before
receiving their test result (95.8%).
5. The coverage of STI test in the last six months was still low (27.9%). Only 39.2% of waria
sought treatment from a health provider and 57.1% of waria recommended their steady
partner to be tested.
6. Face-to-face meeting with a field worker was done by only 39.4% of waria. Printed or audio-
visual material was received by 28.3% of waria, while almost half (48.3%) received free
condom. Only a few were contacted personally by outreach workers (35.1%).
7. The positivity rate of Hepatitis B among waria was 2.9% CI (2.0-4.2) while for Hepatitis C it
was 1.6 CI (0.9-2.6).
8. The proportion of respondents who had knowledge about HIV was still very low (16.4%).

Female Sex Workers (FSWs)

1. As an aggregate the positivity rate of various diseases among FSW was 2.1% for HIV, 1.4%
for Syphilis, 31.1% for Chlamydia, 11.4% for Gonorrhea, and 8.6% for Chlamydia-Gonorrhea
mixed infection.
2. Comprehensive knowledge about HIV prevention and transmission among FSWs was still
low (16.0%). Risk perception among FSWs was also still low (65.5%). Information about HIV
prevention that FSWs were most familiar with was condom use (84.2%).
3. Condom use during the last sex with clients and consistency in condom use in the last week
was low (66.8% and 67.6% respectively). Condom use during sex with non-steady partners
was also low (64.2% during last sex and 57.0% in condom use consistency). Similarly, the

221
 rate was also low with steady partners (22.9% during last sex and 15.5% in condom use
consistency).
4. Coverage of HIV test among FSWs was still low (42.0%). Among FSWs who have had HIV test,
most had their test ≤12 months ago (95.0%). The most common testing locations were
Puskesmas and mobile VCT. Most FSWs also received pre-test counseling.
5. Coverage of STI test in the last six months was low (18.0%). Similarly, few FSWs visited a
health provider for treatment and few recommended STI test to their steady partner.
6. Proportion of FSWs who had meetings with field outreach workers, received printed/audio-
visual material, received free condoms and were contacted by outreach workers in the last
three months was still low.
7. The positivity rate of Hepatitis B and Hepatitis C among FSWs was 1.0% and 0.2%
respectively.
8. Knowledge about hepatitis, hepatitis B and C testing among FSWs was still low.

Clients

1. The positivity rate of HIV among clients as an aggregate was 1.1% and of Syphilis was 2%.
2. Comprehensive knowledge about HIV prevention and transmission was still low (16.1%).
Risk perception among clients was low, and HIV prevention method that most clients knew
was the use of condom.

3. Condom use during the last sex with FSWs and consistency in condom use in the last month
was low. Irrespective of the type of partner (steady or non-steady), condom use in the last
sex was low, and consistency in condom use with a non-steady partner in the last week was
also low.
4. HIV test coverage was still low. Most tests were conducted in Puskesmas and mobile VCT
service, and most clients received pre-test counseling.
5. Coverage of STI test was low. The proportion of clients who sought treatment from a health
provider was also low.
6. The positivity rate of Hepatitis B and C among clients was 1.8% and 0.5% respectively.
7. The proportion of clients who received Hepatitis B and C test was still low.

People who Inject Drugs (PWID)

1. The proportion of PWID who were HIV positive was quite high, at 13.6%. Syphilis infected
only 0.6% of PWID respondents.
2. Overall, 57.4% of PWID had comprehensive knowledge about HIV prevention and
transmission. Information that most PWID were familiar with was the topic on HIV
prevention, i.e. condom use (86.3%) and being faithful to one’s partner (86.1%). Almost

222
 three-quarters of PWID respondents (71.2%) perceived themselves to be at risk of HIV
infection.
3. Condom use during the last sex was highest among respondents who sold sex (51.4%). The
lowest condom use was when respondents had sex with their steady partner (34.1%).
Consistency in condom use in the last month was highest among PWID who sold sex, and
lowest among PWID who had sex with a non-steady partner (17.7%).
4. Exposure of PWID to all four activities of HIV prevention program was below 50%. The
activity that PWID participated most frequently was meetings/discussion about HIV with a
health provider (42.8%). For the other activities, 42.1% of PWID received printed/audio-
visual material about HIV, 28.1% of PWID were contacted by an outreach worker and 21.7%
received free condoms from field/outreach workers.

5. The highest proportion of disease among PWID was Hepatitis C (30.8%), while Hepatitis B
infection was only detected in 2.8% of respondents. Among all the PWID respondents, 7.8%
and 13.3% had Hepatitis B and C test respectively.

9.2 Recommendation
1. The coverage of prevention program in all key populations need to be expanded with a focus
on the following aspects:
a. Considering the proportion of HIV and STI that is quite high among MSM and waria,
prevention programs will need to cover the whole population.
b. Program coverage should also be expanded among FSWs and clients. Eventhough the
proportion of HIV in these populations is still low, but the low condom use in these groups
can potentially result in high transmission that potentially leads to an epidemic.
2. STI intervention program that includes prevention, diagnosis and treatment should be
intensified and expanded to all key populations. This is based on findings about the high rate
of STI, while testing and treatment coverage is still low.
3. Rate of HIV testing is still low. Efforts to proactively bring HIV testing service closer to the key
populations would be necessary.
4. Follow up on all HIV-positive cases is required to ensure commitment to treatment and to
increase viral load testing.
5. Health promotion activities through mass media will be necessary to increase individual’s risk
perception, increase awareness about HIV testing and treatment and reduce stigma.
6. Almost all key populations are internet users, so interventions can be performed through
virtual network and social media.

223
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