Indonesia: HIV/AIDS Research Inventory, 1995-2009

Transcription

INDONESIA
HIV/AIDS Research Inventory
1995-2009
EDITORS : HEPA SUSAMI
SURIADI GUNAWAN
NATIONAL AIDS COMMISSION
2009
SUBHASH HIRA
Since the first confirmed case of AIDS in Indonesia in 1978, the characteristic and magnitude of the HIV/AIDS
epidemic has changed dramatically. The recent estimates of the Ministry of Health Directorate General for
Diseases Control & Environmental Health showed that by December 2008, 293,000 persons were infected and
living with HIV/AIDS. Unprotected sex and the sharing of contaminated syringes are driving the epidemic.
The National Strategic plan (2007-2010) for AIDS Control & Prevention has a special emphasis on research
because it can leverage the quality of AIDS programs in Indonesia. Since the 1990s, many studies in the
field of HIV/AIDS and STI have been conducted in the country. However, there was no repository of these
studies at national level. It was a laborious and time consuming exercise for planners, implementers, experts,
and academicians to search for study results and to identify the gaps. There was a long-felt need to take
stock of research conducted in the country. We are happy to see that the AIDS Research Working Group
of the National AIDS Commission and the Sub directorate AIDS and STI Control, Ministry of Health took
the leadership to prepare and publish a comprehensive inventory of research in Indonesia while the World
Health Organization provided the technical assistance and resources to accomplish this mammoth task.
It is possible that despite repeated efforts of the editors some important published work might have been
missed. Such lack of inclusion of valuable material was unintentional.
We are pleased to present the book entitled “Indonesia: HIV/AIDS Research Inventory 1995-2009” to you.
We hope that program planners, managers, implementers, experts, researchers, and students will find this
book to be a useful reference.
June 2009
National AIDS Commisions
Ministry of Health
Secretary
Dr. Nafsiah Mboi
Director General DC & EH
Prof. Tjandra Y Aditama
HIV/AIDS Research Inventor y 1995 - 2009
iii
Foreword
Foreword
Preface
Preface
Message from WHO Representative to Indonesia, World Health Organization
Since 1981, when AIDS was first reported in the United States of America, HIV has spread rapidly in all
countries of the world. HIV/AIDS is now acknowledged as the most devastating health, socio-economic, and
developmental issue affecting the global community since the 14th century.
Asia is the home to the second highest number of people living with HIV/AIDS after Africa. With over 50 per
cent of the world’s population living in Asia, even a small increase in HIV prevalence translates into large
number of infections. Illiteracy, poverty, economic disparity, and cultural and gender issues contribute to Asia’s
vulnerability to HIV/AIDS and Indonesia is no different.
This book entitled “Indonesia: HIV/AIDS Research Inventory, 1995-2009” has attempted to collect and collate all
published and unpublished research work conducted in Indonesia. The book makes a valuable contribution to
our understanding of the HIV/AIDS epidemic in Indonesia. The valuable lessons learnt so far would be useful in
formulating future policies, designing relevant strategies, and shaping research in Indonesia.
WHO is pleased to support the National AIDS Commission and the Ministry of Health for making the efforts
to collect the reports/articles and publishing this book. I compliment the researchers and editors for their
tireless work.
Jakarta, July 2009
Dr. Subhash R. Salunke
WHO Representative to Indonesia
World Health Organization
Indonesia
v
Since the first confirmed case of AIDS in a foreign tourist was detected in Bali in 1987 the HIV epidemic in
Indonesia has been growing, first slowly until the mid 1990s (driven mainly by unprotected sex) and then more
rapidly in the late 1990s when injecting drug use became an important factor that drove the epidemic. By the
year 2000 the epidemic has reached a concentrated level in many provinces where HIV prevalence is more
than 5 % among injecting drug users, sex workers (male and female) and prisoners. A generalized epidemic is
emerging in the two provinces of Tanah Papua where a prevalence of 2.4 % among the adult population (15-49
year) was found in 2006.
By 31 March 2009 a total of 16,964 cases of AIDS have been reported to the Ministry of Health from 214 cities/
districts in 32 provinces. The number of persons living with HIV/AIDS by December 2008 was estimated by the
Ministry of Health at around 293,000. The number may reach one million by the year 2020 if current trends
continue unabated.
The National Action Plan for HIV and AIDS Control 2007-2010 has targets to reach 80% of the key populations
(injecting drug users, sex workers, warias/transgenders, men who have sex with men and their sexual partners)
with prevention services and provide treatment, care and support (including antiretroviral treatment) for all
AIDS patients who need it. Fighting stigma and discrimination, empowering key populations and supporting
AIDS orphans and vulnerable children are also important targets of the plan.
The plan considered research as one of the priority programs to support policy & planning and improve the
quality and effectiveness of interventions. The research agenda includes operational research in clinical &
non-clinical settings, studies on adherence and drug resistance, epidemiological & socio-behavioral research,
studies on the socio-economic impact of the epidemic and cost-effectiveness studies.
A Working Group for HIV/AIDS Research was established by the National AIDS Commission with the
following tasks:
1. Develop networking and collaboration between universities/centers of research
2. Develop research agendas to support HIV/AIDS programs
3. Improve the quality and utilization of research (through training, workshops, seminars)
4. Improve documentation and dissemination of research results
5. Formulate guidelines for implementation of good research.
The present book “Indonesia: HIV/AIDS Research Inventory 1995-2009” has been compiled by the HIV/AIDS
Research Working Group to implement task no. 4 with the technical assistance of the World Health Organization.
The work started in February 2009 by sending letters to universities, research centers, governmental and nongovernmental organizations, international organizations and UN agencies involved in HIV/AIDS research to
send their research reports (published as well as unpublished).
A search through the internet was undertaken and several universities/research institutions were also visited
by one of us (HS) to collect the reports and articles. As it contains important and useful information, we have
included some reviews, editorials, university theses and results of surveillance surveys in the collection. The
search included studies conducted on Sexually Transmitted Infections (STI) because these are known cofactors
of HIV transmission and strategies for the prevention and control of HIV include interventions for STI.
The published articles, which have been approved by their publishers for reproduction here, are grouped
into chapters on Epidemiology, Socio-behavioral Research, Biomedical & Clinical Studies, and Intervention/
vii
Introduction
Introduction
Introduction
Programmatic Issues. Several articles that were published in Bahasa Indonesia have been translated in to
English with the assistance of medical students’ association and are included in the book.
Published articles/reports, which have not received permission for reproduction, together with the unpublished
articles/reports are included in the Annotated Bibliography. The full text of unpublished articles/reports is
saved on CD provided with the book (see back cover).
We estimate that the 120 articles/reports included in the inventory represent more than 60 % of the
research reports written in the period 1995-2009. We also plan to collect more reports and publish an
inventory of abstracts which have been presented in several international as well as national meetings/
conferences/seminars.
We hope that this inventory will be useful for researchers, planners, managers, students and activists and
contribute to the improvement of the national HIV/AIDS programs. It is available at no cost from offices of
KPAN and WHO.
Finally we acknowledge the assistance and support of the Secretariat of the National AIDS Commission, the
Directorate General of Disease Control & Environmental Health/Ministry of Health and the World Health
Organization, the permission for reproduction by the publishers and the cooperation of authors and institutions
for sharing their reports and documents.
July 2009
Hepa Susami
Suriadi Gunawan
Subhash K Hira
viii
Table of Content
Table of Contents
Foreword ..................................................................................................................................................................................... iii
Preface ........................................................................................................................................................................................ v
Introduction .............................................................................................................................................................................. vii
Table of Contents ..................................................................................................................................................................... ix
Published Articles
Epidemiology & STI
Determinants of Safer-Sex Behaviors of Brothel based Female Commercial Sex Workers in Jakarta,
Indonesia .................................................................................................................................................................................... 1
Comparing Efficiency Of Treatment Of Chlamydial Pelvic Inflammatory Disease (PID)
Using Short- And Standard-Doxycycline Regimens .................................................................................................... 13
Validation of Syndromic Approach for the Management of Sexually Transmitted Infections
among Women with High Risk Behaviour ...................................................................................................................... 21
High rates of sexually transmitted diseases among male transvestites in Jakarta, Indonesia ................. 31
Prevalence of Sexually Transmitted Infections (STI) and High Risk Behaviours among
Male Street Children in Jakarta, 2000 ............................................................................................................................. 39
Incidence of HIV-infected infants born to HIV infected mothers with prophylactic therapy:
Preliminary report of hospital birth cohort study ...................................................................................................... 51
Impact of HIV/AIDS 2005-2025 in Papua New Guinea, Indonesia and East Timor ........................................... 57
Executive Summary: Trend of Risk Behaviours for HIV/STI in Indonesia (Result of IBBS 2007) ................. 67
HIV / STI Integrated Biological Behavioral Surveillance (IBBS) among Most-at-Risk Groups
(MARG) in Indonesia, 2007 ............................................................................................................................................... 71
Social & Behavioral
AIDS knowledge, condom beliefs and sexual behaviour among male sex workers and male
tourist clients in Bali, Indonesia ........................................................................................................................................ 99
AIDS and STD knowledge, condom use and HIV/STD infection among female sex
workers in Bali, Indonesia.................................................................................................................................................. 113
Social Influence, AIDS/STD Knowledge, and Condom Use Among Male Clients of Female
Sex Workers in Bali ............................................................................................................................................................... 123
The Smokescreen of Culture: AIDS and the Indigenous in Papua, Indonesia ................................................. 133
Reasons for not Using Condoms Among Female Sex Workers in Indonesia .................................................... 143
Syphilis and HIV Prevalence among Commercial Sex Workers in Central Java, Indonesia:
Risk-Taking Behavior and Attitudes that May Potentiate a Wider Epidemic .................................................. 157
Voluntary HIV Testing, Disclosure, and Stigma Among Injection Drug Users in Bali,
Indonesia ................................................................................................................................................................................. 165
Factors Influencing Pregnancy Decision-Making of HIV Positive Women in Jakarta, Indonesia ............ 177
ix
Table of Content
Characteristics and Knowledge About HIV/AIDS and Drug Abuse Associated with Inmates
Education Level within Prison Populations in Singkawang, West Borneo in 2006 ...................................... 185
Barriers for introducing HIV testing among tuberculosis patients in Jogjakarta, Indonesia:
a qualitative study ............................................................................................................................................................... 193
Clinical & Biomedical
Sequence Note: Importation of Multiple HIV Type 1 Strains into West Papua, Indonesia (Irian Jaya) ....... 207
Immune Response Towards HIV: Its Significance in Establishing the Diagnosis and
the Stage of Infection ......................................................................................................................................................... 215
Toxoplasma Encephalitis in HIV-infected Person ...................................................................................................... 227
Serological Markers of Hepatitis B, C, and E Viruses and Human Immunodeficiency
Virus Type-1 Infections in Pregnant Women in Bali, Indonesia .......................................................................... 231
Expanded Case Definition for Diagnosing Extrapulmonary Tuberculosis in HIV Infected Person .......... 239
Correlation Between CD4 Count and Intensity of Candida Colonization in The Oropharynx
of HIV-infected/AIDS Patient ............................................................................................................................................ 243
Opportunistic Infection of HIV-infected/AIDS Patients in Indonesia: Problems and Challenge ............. 249
Changes of Opportunistic Infection Pattern in Patients with AIDS in Jakarta ............................................... 257
Pneumothorax in HIV - infected Babies ....................................................................................................................... 261
Clinical Manifestations and Antiretroviral Management of HIV/AIDS Patients with
Tuberculosis Co-infection in Kramat 128 Hospital ................................................................................................... 267
AIDS: From Basic Knowledge to HIV-TB Co-infection ............................................................................................... 277
Simple Methods on Supporting ARV Treatment Services ...................................................................................... 281
Can We Predict Neuropathy Risk before Stavudine Prescription in a Resource-Limited Setting? .......... 285
Intervention & Programmatic Issues
Clients and Brothel Managers in Kramat Tunggak, Jakarta, Indonesia: Interweaving
Qualitative With Quantitative Studies for Planning STD/AIDS Prevention Programs ................................ 293
Evaluation of Training for Sexually Transmitted Disease (STD) Treatment using Syndromic
Approach in several districts of East Java ................................................................................................................... 307
Evaluation of a peer education programme for female sex workers in Bali, Indonesia ............................. 317
Strategy for Control of Sexually Transmitted Infections using The Syndromic Approach
among Women: A Review .................................................................................................................................................. 323
The Current Situation of the HIV/AIDS Epidemic in Indonesia ............................................................................. 335
Public Health - The Leading Force of The Indonesian Response to The HIV/AIDS Crisis
Among People Who Inject Drugs ..................................................................................................................................... 345
Development of HIV/AIDS Module for Medical Students with Problem-based Learning Approach ....... 353
Annotated Bibliography
Annotated Bibliography by Year ..................................................................................................................................... 359
x
Epidemiology & STI
Epidemiology & STI
Determinants of Safer-Sex Behaviors of
Brothel - based Female Commercial Sex
Workers in Jakarta, Indonesia
Endang R. Sedyaningsih-Mamahit1
Steven L. Gortmaker 2
1
Communicable Disease Research Center, National Institute of Health Research
& Development, Jakarta, Indonesia.
2
Harvard School of Public Health, Boston.
J Sex Res. 1999 May;36(2):190-7
Society for the Scientific Study of Sexuality
xiii
Abstract
A cross-sectional survey was conducted in Kramat Tunggak, an official brothel complex in Northern Jakarta. The objectives were to
investigate factors that influence the female commercial sex workers’ consistent practice of condom use. These factors were classified into
personal behaviors and external factors, such as government programs and the brothel managers’ and the clients’ attitudes towards condom
use. After controlling for sociodemographic factors, the sexworkers’ previous experiences in negotiating condom use and in using them for
family-planning purposes were found to be significantly directly associated with consistent condom use. On the other hand, the clients’
and the brothel managers’ attitudinal barriers towards condom use and the sexworkers’ exposure to government programs were inversely
associated with consistent condom use. Changes in the government STD/AIDS-related policy, education, and health programs among the
female sexworker community is urgently needed to substantially increase their condom use practice.
Introduction
The first case of AIDS in Indonesia was found in
1987, and by December 1998 the official number
of reported HIV 1-positive cases was 819, of which
227 were full-blown AIDS cases (Ministry of Health,
1998). There is no doubt that these numbers
represent an undercounting; however, the available
surveillance system in Indonesia did not allow us
to approximate the HIV-1 seroprevalence in this
country. Since heterosexual transmission of HIV-1 is
the predominant mode of transmission in Indonesia,
female commercial sex workers constitute one of the
communities at high risk to become infected with
and to transmit the HIV-1 virus.
Yearly surveys on the prevalence of gonorrhea and
syphilis among brothel and nonbrothel female
sex workers in Jakarta repeatedly showed high
prevalence of both diseases (18-25% and 5-7%,.
respectively) (Gunawan, 1997; Van der Sterren,
Murray, & Hull, 1995). Furthermore, the 1992 and 1994
HIV-l seroprevalence surveys in female sex worker
communities in Jakarta also indicated an increase in
HIV-1 prevalence from 0.3% to 0.6% (Dinas Kesehatan
DKI Jakarta, 1994). These are indications that sex
workers in Jakarta practice unsafe sex behaviors.
A study in East Java province (population 33 million)
showed that 7% of men aged 15 to 60 years had
ever had sex with a sex worker (Linnan, Kestari, &
Kambodji, 1995). Nearly all major cities in Indonesia
have one or more brothel complexes (lokalisasi) and
in Jakarta there are 8 illegal brothel complexes that
have been in business for years, with approximately
10,000 female sex workers. These established brothel
complexes are evidence of a large client base among
the general population. Focusing AIDS prevention
efforts on the female sex worker communities and
the clients is, therefore, justifiable. The current
culturo-political situation in Indonesia, however,
still prevents a public safersex campaign (KOMPAS,
November 7, 1995); therefore, considerable efforts
targeted at brothel communities (i.e., the female sex
workers themselves, the managers, and the clients)
are more feasible and could have a substantial effect
on the predicted AIDS epidemic in this country.
Studies have shown that inconsistent condom use
is ineffective in reducing the risk of STDs or AIDS
infection (Ford & Wirawan, 1996; Sawanpanyalert,
Ungchusak, Thanprasertsuk, & Akarasewi, 1994; Taha
et al., 1996; Zenilman et al., 1995). Therefore, although
it has also been calculated that in a place where HIV-1
prevalence is still low, any increase in condom use
will somewhat reduce the risk of infection (Fineberg,
1988), consistent condom use is the ultimate
behavioral change. Accordingly, this study focused
on consistent use during sexual intercourse.
The government policy toward female sex workers
is mainly to rehabilitate and resocialize them (Dinas
Sosial DKI Jakarta, 1993; Jones, Sulistyaningsih, &
Hull, 1995). Throughout the country, there are 22
rehabilitation centers for sex workers run by either the
national or the provincial government. The Jakarta
Social Welfare Office (referred to as “the Office”) runs
one such center in Kramat Tunggak, Northern Jakarta.
Here, female sex workers and brothel managers are
1
Epidemiology & STI
Determinants of Safer-Sex Behaviors of
Brothel - based Female Commercial Sex
Workers in Jakarta, Indonesia
Epidemiology & STI
still allowed to carry out their business, albeit under
some regulations and restrictions.
Since the Office exercises substantial control over
the Kramat Tunggak brothel complex, its policies
and programs for the sex workers, managers,
and clients, or the lack thereof, may be influential
determinants of the sex workers’ safer-sex practice.
The office provided a monthly health service to the
sex workers, which the women were required to
attend. Those who refused to come, however, were
not penalized. Although the Office had no wellplanned STD/AIDS-related educational programs
in addition to this health program, condoms were
occasionally mentioned in their regular talks, which
were attended each time by about 100 sex workers
and a few brothel managers.
official civil guards who are posted at the two main
entrance gates, which abut two spacious parking
lots available for Kramat Tunggak guests only. On
average, each brothel manager employs 5 to 10
sex workers; usually these women have to pay the
managers for their room, water, and electricity. The
women also have to share their earnings with their
managers, as the clients pay the women directly.
The percentage varies according to each brothel,
but 25% for the managers is the average proportion
(Sedyaningsih-Mamahit, 1997). The Office is located
across the street from the brothel complex. The
rehabilitation and resocialization programs include
some vocational training classes, such as literacy,
sewing, and cooking, which are held in an adjacent
building.
Measures
Other powerful decision makers in a brothel
complex are the brothel managers and the clients
(Swaddiwudhipong, Chaovakiratiping, Siri, &
Lerdlukanavonge, 1990). Clientrelated factors, such
as types of clients, clients’ attitudes toward condom
use, number of clients, and price per sexual encounter
may be important determinants for the sex workers’
consistent condom use (Mhalu et al., 1991; Pickering,
Quigley, Hayes, Todd, & Wilkins, 1993).
In addition, certain sociodemographic factors, such
as age, educational attainment, hometown, and years
of working as a sex worker, may also influence safersex behaviors (Pickering et al., 1993; Wilson, Sibanda,
Mboyi, Msimanga, & Dube, 1990).
Methods
Participants
Our study population was the female sex worker
community in Kramat Tunggak, Northern Jakarta.
Since Kramat Tunggak is a unique place, a brief
description is necessary.
It has a total area of 11.5 hectares (approximately
28.4 acres) and is semi-isolated from the surrounding
residential neighborhoods by a two-meter-high
brick wall. Officially, only the sex workers are
allowed to live there; the brothel managers are only
permitted to come on a daily basis, and no children
are allowed to enter. In reality, however, many of
the brothel managers live there with their families
and bodyguards. The complex is guarded by
2
This study used the AIDS Risk Reduction Model
(ARRM) (Catania, Kegeles, & Coates, 1990) with
the inclusion of elements of the Health Belief
Model (HBM) (Janz & Becker, 1984) and Bandura’s
concept of self-efficacy theory (Bandura, 1989).
The questionnaire was developed through several
stages with the help of experts and the use of several
other researchers’ questionnaires as models and/or
comparisons (Basuki, 1991; Rahardjo, 1992; Wingood
& Case, personal communication, 1994). It is based
on theories and models used in developing questions, both general and behavioral (Ajzen & Fishbein,
1980; Bandura, 1977, 1989; Catania et al., 1990;
Fowler & Mangione, 1990; Janz & Becker, 1984), and
on preliminary qualitative research conducted at the
study site in June and July, 1993. The questionnaire
assessed the following: (a) sociodemographics, (b)
occupational-related information, (c) STD/AIDSrelated behavioral information, and (d) other health
risk behaviors.
To improve accuracy, questions about condom use
referred to the previous two weeks only. Condom
use was initially measured as a percentage (i.e., the
number of clients who used condoms divided by
the number of all clients). This was based on the
assumption-supported by the preliminary studythat most sex workers had only one intercourse per
client. The term client encompassed all males who
received sex services from the sex workers, including
occasional clients (tamu), regular clients (kenalan),
and the women’s lovers (gendak).
After one and a half months (May-June 1995), data
were obtained from 459 survey respondents. The
initial response rate was 63%: About 5% of the
nonrespondents refused to participate, while the rest
(32%) were either not present or were not recognized
in that brothel (the original Office name list was
handwritten and sometimes hard to read).
To estimate the reproducibility of data on consistent
condom use, a 2 week test-retest reliability assessment
was conducted on a random subset of the sample (N
= 46), while their validity was estimated by comparing
them with condom use data obtained in 2-week diaries,
filled out by a small number (N = 40) of participants
randomly. chosen from the survey participants. For
two weeks, these women were asked to afix a green
sticker with a man’s picture on it for every client she
had sex with; a red sticker with the picture of a heart
on it for every sex act with a lover; and a yellow sticker
with a picture of a condom on it beside the stickers
of the clients and lovers when they used a condom in
intercourse. They were also asked to collect their used
condom wrappers to be matched with their condom
use records in the diaries.
Test-retest reliability analysis showed that the
sex workers’ self-reported condom use showed a
moderate reproducibility, with Spearman correlation
estimated as 0.38 (p < .04). The relative validitycomparing self-reported data with diary data-was
also moderate. The Spearman correlations were
estimated as 0.61 (p <.004) and 0.52 (p <.02).
As we realized that the sex workers might be telling
us what they believed we wanted to hear, we also
conducted an extensive qualitative study. This was
carried out between April and November of 1995,
mainly by the primary investigator. Respondents were
chosen using predetermined criteria, (such as age,
sex, and size of brothel) from among the sex workers,
the brothel managers and bodyguards, the clients
(convenience samples), the vocational trainers, and
government officers (see Sedyaningsih-Mamahit,
1997 for findings from this qualitative study).
Statistical analyses
Data were initially recorded in Epi-Info (Center for
Disease Control, 1990). Univariate, bivariate and multivariate analyses were carried out using STATA (STATA,
1993). Our main outcome variable was consistent
condom use. Condom use was classified as 0 (never), 1
(seldom), 2 (often), or 3 (always) and for the final analysis,
into 1 for always and 0 for others. The association
of consistent condom use with other variables was
estimated by odds ratios in logistic regressions. The
sample size varied because of missing data: Condom
use was reported only by those indicating vaginal sex
during the previous two weeks.
Condom use reproducibility and validity was assessed
by Spearman correlation coefficients between selfreported and retest data, and between self-reported
and diary data.
Results
Descriptive Analysis
Sociodemographic characteristics. In general, the
characteristics of our study samples, the sex workers
who refused to become respondents, and the entire
Kramat Tunggak sex worker population (data from the
May, 1993 census) are quite similar. Table l indicates
that we surveyed more educated sex workers as
respondents (4.7% or n = 18 attended senior high
school), compared to the nonrespondents (1.5% or n
= 4), a very likely scenario, as it is likely that they have
more self-confidence.
The government policy regarding marital status may
explain the difference between our respondents
3
Epidemiology & STI
Procedure
Respondents for the survey were randomly chosen
(using a random number list) from the sex worker
name list recorded by the Office in April, 1995. At
that time, 1,600 women and 228 brothel managers
were officially registered in Kramat Tunggak. The
only exclusion criterion for our survey was if the sex
workers had been trained by Yayasan Kusuma Buana
(YKB), a nongovernment organization that had
given about 80 sex workers a 3-day intensive STD/
AIDS training course in 1994 (Sasongko, personal
communication, 1995). Ten women, ages 20 to 30,
conducted the face-to-face interviews. Using an
available area map, our team visited the first 500
selected sex workers in their brothels during the
daytime. Those who refused to participate and those
who were not found after two visits were dropped,
and other names were selected randomly to replace
them using the random number list. Most of the sex
workers who agreed to participate fully in the study
signed or fingerprinted a written consent; only a few
agreed verbally.
Epidemiology & STI
came from poor families, so it was. not a surprise
to learn that about 63% (n = 291) were motivated
by reasons that included economics. Motivation
was determined using an openended question, in
which the women could relate their personal stories.
In Indonesia, where being a sex worker is highly
stigmatized, it is interesting to see that 13% (n = 60)
of the women frankly stated that they chose, and
were not forced into, sex work. Nearly 15% (n = 67)
also mentioned that they enjoyed working as sex
workers. The remaining sex workers’ motivations
to enter the job included disharmony with their
significant men and other stressful conditions (24%
or n = 108). Previous experience of being raped was
not a commonly reported “push” factor: Only 5% (n =
25) of the sex workers reported being raped before
entering prostitution.
More than half the women had tried different jobs
before entering the sex industry; working in a factory
was the most popular job. From the qualitative study
we found that not only did these jobs yield much less
money (the average wage was $45.00 per month),
but the working hours were also much longer than
commercial sex work.
and the general Kramat Tunggak population. This
policy only allows divorcees, widows, and nonvirgin
unmarried women (“holed girls” or gadis bolong is the
official term for these women) to work as sex workers
in Kramat Tunggak: Virgins and married women are
prohibited. It was no surprise, therefore, to see that no
married women were officially registered; nevertheless,
interviews revealed that married women did work in
Kramat Tunggak (5.2% or n = 24).
Data on the number of years worked in Kramat
Tunggak show that we missed more new sex workers;
again, a very likely scenario since they were probably
afraid of us. More than 80% (n = 382) of the sex workers
had worked for 2 years or less in Kramat Tunggak. This
finding was not only in accordance with the Kramat
Tunggak census, but also with data on other brothel
complexes in Jakarta (Basuki, 1991).
Occupational-related characteristics. The respondents’
occupational-related characteristics are displayed in
Table 2. Most of the sex workers in Kramat Tunggak
4
Although only 59% (n = 269) of the women adopted
at least one measure to prevent pregnancy, 12.4%
(n = 57) had induced abortion. The seemingly low
number of unwanted pregnancies may be due to the
sex workers’ habit of drinking traditional herbs, or to
pelvic inflammatory disease (PID) as a complication
of repeated STDs.
Features of the sex workers’ sexual behaviors showed
their practices over the previous two years and some
over the previous two weeks. In line with others’
unpublished findings (Basuki, 1991; Rahardjo, 1992),
we too found that vaginal sex was the most preferred
type of sex, and no one reported having anal sex. The
5.9% (n = 27) who said they had not had vaginal sex
over the previous two weeks were sex workers who
for various reasons did not receive any clients during
that time.
More than half of the women had had fewer than
7 clients in the previous two weeks (this finding
was similar to that from another study of a different
Jakarta brothel complex by Basuki, 1991). This was
due to the fact that many clients come just to drink
beer and to dance, and many of the women only
Predictors of Consistent Condom Use
Before adjusting for other factors, several variables
were significantly associated with consistent condom
use. In the multivariate analysis, however, some of
those associations became statistically insignificant. In
multivariate logistic regression analysis, all statistically
significant factors (p < .05) from the bivariate
analyses-as well as other factors that we thought
were conceptually important in predicting consistent
condom use-were initially included in the model.
Hence, we were testing the direct association between
factors from the three different stages of the AIDS Risk
Reduction Method and consistent condom use.
Variables that remained significant-as well as factors
that are conceptually important-were kept in the
final model. Thus, we ended up with one final model
to predict consistent condom use (see Table 3).
Sociodemographic characteristics. Independent of the
other variables in the model, sex workers from Central
Java and Yogyakarta were more likely to practice
consistent condom use than their colleagues from
either West or East Java. The odds that these women
practiced consistent condom use were nearly two
times their colleagues (OR = 1.8; CI = 1.03 - 3.15).
Data showed that the longer the sex workers worked
it Kramat Thnggak, the less they would practice
consistent condom use. The “longest term” women
were about si) times less likely to practice consistent
condom use wher compared to others (OR = 0.18; CI =
0.07 - 0.43). From the qualitative study we learned that
the longer-term womer usually had regular clients or
lovers. Since these were alsc the clients least likely to
use condoms, we suspected that this might be the
cause. Another reason may be that these women felt
they were experienced enough to select which clients
were healthy and which were not, although their
concept of healthy was actually “clean in appearance.”
gave sexual service to regular customers or lovers,
who would visit and pay on a regular basis.
One percent (n = 5) of the women said that they had
never seen a condom before; all of them were new
to the job. An estimated 36% (n = 154) of the sex
workers said that they required their clients to use
a condom all the time, and 25% (n = 108) said they
Another interesting fact was that the higher the
women’s previous monthly income, the less they
would practice consistent condom use (p for trend
test < .002). A similar result was found for the variable
number of clients over the previous two weeks: The
more clients the women had, the less they practiced
consistent condom use (p for trend test < .006).
5
Epidemiology & STI
never required their partners to use condoms when
engaging in vaginal intercourse.
Epidemiology & STI
How much clients pay for sex has been found to be
a factor that determines sex workers’ condom use
(Mhalu et al., 1991; Pickering, Quigley, Hayes, Todd,
& Wilkins, 1993). In Kramat Tunggak, however, the
prices for different sex services (i.e., short time and
overnight) were more or less fixed.
Unfortunately, our questionnaire provided limited
data about the sex workers’ current economic status.
Since our income data only referred to the previous
month and prices were fixed, this information was
more of an indication of the number of clients served
by the women than of their economic status. Our
income data were positively correlated to the number
of clients served: The Spearman correlation was
0.39 (p < .0001). Regression analysis also indicated
that every increase of 7 clients was associated with
6
an income difference of Rupiah (Rp.) 240,530.00
(approximately $109.00), or about Rp. 34,000.00
per client (approximately $15.00), which is similar
to results of the qualitative study (i.e., the prices for
short time and overnight sex were Rp. 15,000.00,
or about $7.00, and Rp. 40,000.00, or about $18.00
respectively). Currency values are based on exchange
rates at time of this study.
In the bivariate analysis, the number of clients over
the previous two weeks also showed a negative
association with consistent condom use: The more
clients the women had, the less they practiced
consistent condom use (p for trend test < .006).
Therefore, we used only one variable, such as
the number of clients, in the multivariate logistic
regression.
The sex workers’ personal determinants. In the final
model, knowledge about STDs and AIDS, perception
of susceptibility and severity of the diseases,
attitudes, and self-efficacy in using condoms did not
significantly predict consistent condom use. On the
other hand, women who had ever used condoms for
family planning purposes were 9 times more likely to
use condoms consistently (OR = 9; CI = 1.85 - 45.08),
and the women most experienced in negotiating
condom use were 5 times more likely to practice it
consistently than the least experienced ones (OR = 5;
CI = 2.16 - 12.25).
However, in a separate multiple linear regression
model with experience in negotiating condoms
as the outcome variable and other factors as
independent variables, we found that this experience
was significantly predicted by knowledge of STDs (p
< .0001), positive beliefs about condoms (p < .0001),
and self-efficacy in using condoms (p < .0001).
External factors. In the final model, one external
factor was significantly associated with consistent
condom use: Women who perceived the clients’
and managers’ rejection of condoms as high were
eight times less likely to practice consistent condom
use than women who perceived the rejection to be
low (OR = 0.12; CI = 0.06 - 0.27). It was difficult to
separate the clients’ attitudes from the managers’
in our data; however, the fact that the managers
consistently providing condoms in their brothels did
not significantly increase the women’s consistent
condom use might mean that the client factor was
the more important one.
Since the number of women who received treatment
and/or examination from the government monthly
mobile service was too small, this variable was
dropped, and only the variable of gaining AIDS
knowledge from the government’s talks was used
to represent the influence of government programs.
This variable had a negative impact on the sex
workers’ consistent condom use (OR = 0.58).
Further analysis showed that this variable was
negatively confounded by multiple factors, such as
years of working in Kramat Tunggak and education.
As both were inversely associated, it seemed that the
longer the women worked in Kramat Tunggak and
the higher their level of education, the less likely they
would attend the government talks. However, after
controlling for these confounding factors, attending
the talks was still inversely associated with the
women’s consistent condom use, suggesting that the
government program is ineffective.
Discussion
We have conducted a behavioral survey among
brothelbased female sex workers in Kramat Tunggak,
the largest and only official brothel in Jakarta. A large
proportion (±28%) of participants were randomly
chosen from among the population living and
working in the complex, implying representativeness
of the data obtained. Realizing that participants
might give answers just to please the researchers,
we have also conducted an extensive qualitative
study to verify certain aspects of the participants’ sex
behaviors, especially regarding their condom use.
We found that only 36% (n = 154) of the participants
reported always using condoms during the previous
two weeks, 25% (n = 108) never used condoms at
all, and the rest (39%) used condoms occasionally.
The pattern of condom use in this community was
not consistent over time: The reproducibility of these
data in test-retest interviews was moderate, and
when validated with diary data, showed a moderate
correlation. Our qualitative study indicated that this
inconsistency was mainly due to real inconsistency’in
condom use practice, and not because participants
lied to us.
After adjusting for sociodemographic variables,
participants’ consistent condom use was significantly
7
Epidemiology & STI
In the multivariate model, the negative association
between number of clients and condom use
persisted. The cross-sectional study design, however,
did not allow us to estimate a temporal relationship
between them. Our qualitative study indicated that
many sex workers, in their anxiety over losing their
clients, were reluctant to insist that their clients use
condoms. We assumed it was more likely that less
consistent condom use caused the number of clients
to increase, rather than the other way around. As the
number of clients was also positively correlated with
the number of years of working in Kramat Tunggak
(Spearman rho: 0.12, p < .009), it could also be that
many of those clients were either the regulars and/
or the lovers, who were less likely to use condoms.
Since the reverse causal path was a likely reason for
this association, we decided to exclude the number
of clients from the final model.
Epidemiology & STI
and directly associated with their experience in
using condoms for family planning purposes and
their experience in negotiating condoms with clients
in previous times. On the other hand, significant
inverse associations were found with the women’s
length of time as sex workers in Kramat Tunggak,
their perceived rejection of clients and managers,
and government talks as the source of their AIDS/
STD knowledge.
Focusing efforts to modify the above factors may substantially change the women’s condom use behavior,
and may in turn reduce the spread of HIV-1 infection
in this community. Trying to work within the existing
system, we suggest interventions that place the
programs’ providers as main actors, involving the sex
workers, the clients, and the brothel managers.
Although officials publicly state that condom use is
promoted in areas with a high rate of prostitution to
prevent men from getting AIDS, during the study we
found that the government only had two programs
to support condom use: the occasional talks and the
monthly health services. In order to promote condom
use and other safer-sex behaviors of the sex workers,
the government should develop more aggressive
and effective health services and education programs
for the sex workers, the brothel managers, and the
clients.
More regular and systematic talks to smaller groups,
preferably based in only one brothel, with more discussions that involve everyone in the brothel including
the managers, may be a more constructive way of
communicating STD/AIDS knowledge and prevention
measures to the sex workers. As condom negotiating
and technical skills are important predictors for the
women’s consistent condom use, they should be
included in the training curriculum. Moreover, as
previous experiences in using condoms with clients or
for family-planning purposes were very significant in
promoting consistent condom use, it is best that the
government not give sporadic talks or short, intensive
condom-training programs, but should have more
lengthy regular classes, similar to their other vocational programs. This way, the sex workers will have a
chance to build their self-efficacy in using condoms by
practicing their negotiating skills, and to revise them
using friends’ comments as inputs.
8
In our opinion, a daily clinic located inside the Kramat
Tunggak complex would be more effective than a
monthly mobile health service: Data showed that only
a few sex workers got STD examination/treatment
from the current monthly service. It should be staffed
by doctors, nurses, and other health counsellors who
are female, and its services should be both userfriendly and out-reaching. This clinic should primarily
address the sex workers’ health concerns, which do
not necessarily mean STD problems. Only by doing
this will the clinic gain the trust of the sex workers.
The biggest hindrance in setting up the clinic will be
the government’s reluctance to provide official health
service for sex workers out of fear of public protest,
since this maybe misinterpreted as an act legitimizing
prostitutioi (Sihombing, personal communication,
1995). Nevertheless if the government is to work
toward the women’s socia rehabilitation and not just
oversee a quasi-legal brothel, it must begin to focus
on returning healthy women to th, community. A
health clinic within Kramat Tunggak is necessary first
step in this direction.
Another significant factor that hinders the sex
workers consistent condom use is the managers’ and
clients’ attitude toward condom use. To overcome
this, the governmen should have a formal policy on
condom use in Krama Tunggak (and other brothels in
Jakarta). In most of th. brothels in Kramat Tunggak,
one can see signs such as “Ni guns or sharp weapons
allowed,” or “Sorry, for security’ sake, we will knock on
your door every half hour. Managers posted these
signs to comply with governmen safety regulations.
If managers put up signs stating that con dom use
is a must in the brothel, the sex workers will thei be
legally empowered to negotiate condom use with
thei clients. The managers could also support this by
either providing free condoms or by selling condoms
in their brothels Direct programs targeted to clients
in the general popu lation are still difficult to launch
in Indonesia, since this ac will be interpreted as
enhancing promiscuity. Interventioi programs for
these men can, therefore, only be conducte (in
brothel communities and in STD clinics; both still
fail to attract the government’s current attention.
With regard to the brothel communities, billboards
and posters to encour age condom use should be
put up in brothel complexes Condom booths, where
Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A decade
later. Health Education Quarterly, 11, 1-47.
Finally, our study has shown that combining a
behavioral survey with a qualitative study enables us
to understand the data better. In the future, a survey
among the general population surrounding brothel
complexes should also be conducted to understand
their involvement with the sex workers inside. The
results may be used as a basis for expanding thesafer-sex information campaigns outside o the
brothel complexes.
Linnan, M., Kestari, M., & Kambodji, A. (1995). Adult sexual behavior
and other risk behaviors in East Java: Behavioral surveys from
urban, periurban and rural areas of East Java. Unpublished
manuscript.
References
Pickering, H., Quigley, M., Hayes, R. J., Todd, J., & Wilkins, A. (1993).
Determinants of condom use in 24,000 prostitute/client
contacts in The Gambia. AIDS, 7, 1093-1098.
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and
predicting social behavior Englewood Cliffs, NJ: Prentice-Hall,
Inc.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ:
Prentice Hall, Inc.
Bandura, A. (1989). Perceived self-efficacy in the exercise of control
ove AIDS infection. In V. M. Mays (Ed.), Primary prevention
of AIDS Psychological approaches. Newbury Park, CA: Sage
Publications.
Basuki, E. (1991). Perilaku berisiko tinggi terhadap AIDS pada
kelompok wanita tuna susila Kecamatan Pasar Rebo Jakarta
Timur [AIDS-related high risk behaviors among female sex
workers in Pasar Rebo district Eastern Jakarta]. Unpublished
manuscript.
Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an
understanding of risk behavior: An AIDS Risk Reduction Model
(ARRM). Health Education Quarterly, 17, 53-72.
Centers for Disease Control and Prevention. (1990). Epi-Info 5.0.
Atlanta, GA: CDC Press.
Dinas Kesehatan DKI Jakarta [Jakarta Health Provincial Office].
(1988-1995). Archives Year 1995. Jakarta, Indonesia.
Dinas Sosial DKI Jakarta [Jakarta Social Welfare Provincial
Office]. (1993, December). Himpunan peraturan tentang
Panti Rehabilitasi Wanita Tuna Susila Dinas Dosial DKI
Jakarta [Collections of rules and regulations on sexworker
rehabilitation programs). Jakarta, Indonesia: Dinas Sosial DKI
Jakarta.
Jones, G. W., Sulistyaningsih, E., & Hull. T. H. (1995). Prostitution
in Indonesia. Canberra, Australia: The Australian National
University Press.
Mhalu, F., Hirji, K., Ijumba, P., Shao, J., Mbena, E., Mwakagile, D.,
Akim, C., Senge, P., Mponezya, H., Bredberg-Raden, U., &
Biberfeld, G. (1991). A cross-sectional study of a program for
HIV infection control among public house workers, Journal of
Acquired Immune-Deficiency Syndrome, 4, 290-296.
Ministry of Health, Republic of Indonesia: Subdirectorate of STD,
AIDS and Yaws Control, Directorate General of Communicable
Disease Control & Environmental Health. (1998). Monthly
Report of December, 1998. Jakarta, Indonesia.
Rahardjo, H. (1992). Isu don pemahaman AIDS terhadap penghuni
di lokalisasi WTS di Kramat Tunggak [Knowledge of AIDS
among female sex workers in Kramat Tunggak]. Unpublished
manuscript.
Sawanpanyalert, P., Ungchusak, K., Thanprasertsuk, S., & Akarasewi,
P. (1994). HIV seroconversion rates among female commercial
sex workers, Chiang Mai, Thailand: A multi cross-sectional
study. AIDS, 8. 825-829.
Sedyaningsih-Mamahit. E. R. (1997). Clients and brothel managers
in Kramat Tunggak, Jakarta, Indonesia: Interweaving
qualitative with quantitative studies for planning STD/AIDS
prevention programs. Southeast Asian Journal of Tropical
Medicine and Public Health, 28, 513-524.
Stata Corporation (1993). Reference Manual 1,2,3. College Station,
TX: Stata Press.
Swaddiwudhipong, W., Chaovakiratiping, C., Siri, S., &
Lerdlukanavonge, P. (1990). Sociodemographic characteristics
and incidence of gonorrhea in prostitutes working near the
Thai-Burmese border. Southeast Asian Journal of Tropical
Medicine & Public Health, 21, 45-52.
Taha, T. E. T., Canner, J. K., Chiphangwi, J. D., Dallabetta, G. A.. Yang. L.
P., Mtimavalye, L. A. R., & Miotti, P. G. (1996). Reported condom
use is not associated with incidence of sexually transmitted
diseases in Malawi. AIDS, 10, 207-212.
Fineberg, H. (1988). Education to prevent AIDS: Prospects and
obstacles. Science, 239, 592-596.
Van der Sterren, A., Murray, A., & Hull, T. H. (1995). A history of
sexually transmitted diseases in the Indonesian archipelago
since 1811. Canberra, Australia: Australian National University
Press.
Ford, K., & Wirawan, D. N. (1996). Behavioral interventions for
reduction of sexually transmitted disease/HIV transmission
among female commercial sex workers and clients in Bali,
Indonesia. AIDS, 10, 213-222.
Wilson, D., Sibanda, B., Mboyi, L., Msimanga, S., & Dube, G. (1990).
A pilot study for an HIV prevention programme among
commercial sex workers in Bulawayo, Zimbabwe. Social
Science & Medicine. 31, 609-618.
Fowler, Jr., F. J., & Mangione, T. W. (1990). Standardized survey
interviewing: Minimizing interviewer-related error Newbury
Park, CA: Sage Publications.
Zenilman. J. M., Weisman, C. S., Rompalo, A. M., Ellish, N.. Upchurch,
D. M., Hook III, E. W.. & Celentano, D. (1995). Condom use to
prevent incident STDs: The validity of self-reported condom
use. Sexually Transmitted Diseases, 22, 15-21.
Gunawan, S. (1997). Sexually transmitted disease control programs
in Indonesia. Paper presented at the 4th International Congress
on AIDS in Asia and the Pacific. Manila, The Philippines.
Indonesian Health Ministry (November 7, 1995). Pemerintah tak
promosikan penggunaan kondom [Government will not
promote condom use]. KOMPAS.
Manuscript accepted November 23, 1998
9
Epidemiology & STI
the clients can buy condoms as well as receive free
leaflets about STDs, AIDS, and condoms should be
placed in strategic places inside the complexes.
Translated from Perbandingan Efisiensi Pengobatan Penyakit Radang Panggul (Prp) yang disebabkan oleh Infeksi Klamidia
dengan Doksisiklin 100 Mg Regimen Singkat dan Regimen Baku.
Endang R. Sedyaningsih 1
Basuki Mulyono2
MJN R. Mamahit3
Siti Dhyanti Wisnuwardhani4
Gulardi H. Wiknjosastro2
1
Communicable Disease Research Center, National Institute of Health Research &
Development, Jakarta, Indonesia.
2
RSUD Koja.
3
RSUD Tangerang.
4
RSUPN Dr. Cipto Mangunkusumo Jakarta.
Majalah Obstet Ginekol Indones. 2000 Apr;24(2):97-103
Perkumpulan Obstetri Dan Ginekologi Indonesia
11
Epidemiology & STI
Comparing Efficiency Of Treatment Of
Chlamydial Pelvic Inflammatory Disease (PID)
Using Short- And Standard-Doxycycline Regimens
Abstract
Objective: To test whether short regiment of Doxycycline 100 mg is as effective as standard regiment of Doxycyciine 100 mg for Pelvic
Inflammatory Disease (PID) cases caused by chlamydial infection.
Design/data identiication: Randomized controlled triad.
Materials and methods: Women with lose abdominal pain who visited the gynecology clinics in Dr. Cipto Mangunkusumo hospital, Kcrja
hospital and Tcnagerang hospital were randomly assigned it) receive Do.Dcycline l0i) nag regular treatment for chiamydia (orally twice a day for
2 weeks) or short treatment (orally twice a day far I week). Both groups received similar regiment for gonorrheal infection. Clinical diagnosis of
PID was confirmed by GenProbe laboratory test.
Results: 95 patients diagnosed with PID received regular treatment and 89 patients received short regiments. Results of the regular ire atmeat
were slightly better than the short regiment (RR: 1.2; p value: 0.005). However, both regiments showed na difference in results among patients
with high treatment compliance (RR: 1.1; p value: 0.41), and among patients with GenProbe chlamydia positive (RR: 0-9;p value:0.72).
Conclusions: Regular treatment for chlamydia gave a slightly better result thin the short regiment in PID patients. This difference disappeared
when compliance and the causal microorganism were taken into account in the analyses.
[lndones J Obster Gynecol 2000; 24:97.103]
Keywords: Pelvic Inflammatory Disease (PID), chlamydia, Sexually Transmitted Infection (STI).
Introduction
Pelvic Inflammatory Disease (PID) is the infection
of upper reproductive system of women, mainly
through spread from the lower reproductive system
(for example: vagina and cervix); this infection may
involve the endometrium, tubes, ovaries, and their
surrounding tissues.1 Complications of PID often
occur and its sequelae frequently persist, such as
blocked fallopian tubes that lead to infertility, ectopic
pregnancy, chronic pain in the pelvic region, and
recurring PID. In developing countries, incidence
of these complications is higher than in developed
countries because of delayed, inadequate, underdosage, or lack of treatment.
In Indonesia, incidence of PID is not precisely know,
but in 1992, WHO estimated the prevalence of
infertility (primary and secondary) to be 22%,2 and
the ectopic pregnancy rate in 1960-1980 to be 5.811 per 1000 fertilizations.3 Other studies in Jakarta
show that 42% of infertility in women are due to tube
infections,4 and 68.8% of ectopic pregnancies are
also preceded by tube infections.3 Therefore it can be
concluded that PID is also a significant health problem
for women’s reproductive health in Indonesia.
Research in the international world shows that
most PID are associated with sexually transmitted
infections (STI), especially gonorrhea and/or
chlamydia.1,4,5,6 One of those two microorganisms
can be isolated from around two-third of PID
cases.7,8 Among Indonesian women who are not sex
workers, gonorrhea does not present as a problem;
the proportion of gonococcal infections in women
who complain of white discharge in RSCM is less
than 2%9 and the gonococci are found in less than
1% of outpatient attenders in primary health care
centers (Puskesmas) in Northern Jakarta.10 On
the other hand, chlamydial infections are found
amongst 19% of patients with white discharge at
RSCM11 and amongst 10.3% of attendees at birth
control clinics in Northern Jakarta.8 From these data
it is estimated that chlamydial infection is one of the
main causes of PID in Indonesia.
Diagnosing PID correctly is difficult task. Laparoscopy
as a golden standard for diagnosing PID is a risky
and expensive diagnostic tool; even more, it misses
diagnoses on 20% of all cases.7 Based on this,
clinicians make presumptive diagnoses based on
13
Epidemiology & STI
Comparing Efficiency Of Treatment Of
Chlamydial Pelvic Inflammatory Disease (PID)
Using Short- And Standard-Doxycycline Regimens
Epidemiology & STI
clinical diagnosis, which sometimes are supported
by laboratory tests. Considering the severity of its
complications, Centers for Disease Control (CDC)
Atlanta recommends a simplified clinical criteria
for diagnosis, which is the presence of: 1) lower
abdominal pain; 2) cervix pain associated with
movement; and 3) adnexal pain.12 Due to the
frequency of PID cases caused by gonococcal and/or
chlamydial infections, recommended PID treatment
regimens should include antibiotics effective
against both C. Trachomatis, N. Gonorrhoeae5,7,12
and anaerobic bacteria, one of the other causes of
PID. Because lab tests for gonorrhea and chlamydia
are complex to carry out, not always accurate, or
often unavailable, treatment may be given without
conducting or without having to wait for lab results.
One regimen of chlamydial treatment which is
recommended by CDC is doxycycline 100 mg twice
daily for 14 days.6 The length of this regimen is
burdening for the patient in terms of costs (ranging
from Rp. 16.000 – Rp. 105.000) and also requires
compliance. It is also suggested that the patient
abstain or has sex only using condoms for quite a long
time. These factors may influence the completion
of this chlamydial treatment. On the other hand, a
shorter doxycycline therapy, which is doxycycline
100 mg twice daily for 7 days (ranging from Rp. 8.000
– Rp. 52.000) is proven to be adequate in treating
cervicitis without associated complications.
This study aimed to test whether the shorter
doxycycline therapy, which is doxycycline 100 mg
twice daily for 7 days, is as effective for PID treatment
as the standard regiment of doxycycline 100 mg
twice daily for 14 days. Besides, it is also to assess
the prevalence of chlamydial infection among PID
patients at several hospitals.
Materials And Methods
The sample population was patients attending the
gynecology clinic at RSUPN Cipto Mangunkusumo,
RSUD Koja, and RSUD Tangerang Hospitals in Jakarta.
To survey chlamydial and gonococcal infections, all
patients with the following inclusive criteria were
taken: a) woman, b) aged 15-60, and c) complaint of
lower abdominal pain. The exclusion criteria were: a)
pregnant, and b) have undergone hysterectomy. For
the treatment regimens those clinically diagnosed as
PID patients were taken. The diagnostic criteria were:
a) complain of lower abdominal pain and having
cervix pain associated with movement with the
14
bimanual examination, and b) complain of adnexal
pain. A random half of the PID cases were given
standard chlamydial treatment regimen and the
other half received the short regimen. All cases were
given the same treatment for gonorrhea.
Sample calculations were done using Epi-Info.13
Assuming that the prevalence of chlamydia in this
population is 10%, a difference in therapy results
between the standard and short regimens will be
achieved if < 20%, with 95% certainty (confidence
interval) and 80% power, 90 patients are needed
for each regimen. By having 3 study locations, 30
patients are needed from each site.
After a bimanual vaginal examination it was clinically
determined whether a patient had PID or not. A
lab test using the Genprobe method was done
on endocervical, both those diagnosed with and
without PID. This test was done to detect infection by
Chlamydia trachomatis and Neisseria gonorrhoea.e
Recovery was assessed at 14 days after the first visit, both
for the patients receiving the standard regimen and
short regimen, and was based on the disappearance
of cervix pain on movement and adnexal pain (clinical
recovery) as well as based on conversion of the repeated
lab results (bacteriological recovery).
Several risk factors that were commonly listed in
the patient’s gynecological medical record were
measured, such as: previously having similar
symptoms, usage of contraceptive devices, and
history of abortion.
The data were computerized using Epi-info program.
The RR of chlamydial (and gonococcal) infection on
the PID and non-PID patients was calculated, and
later the RR of those who recovered after being given
standard and short regimens. Calculations using chi
square were performed to see if the proportion of
recovered patients on both groups were significantly
different.
Results And Discussion
Generally patients at RSUD Koja, RSUPN Cipto
Mangunkusumo, and RSUD Tangerang don’t differ
much. The patients of RSUD Tangerang Hospital are
slightly younger compared to the two other sites.
From their educational profile, patients from RSUD
Koja are slightly higher than the other two locations.
Table 1. Reproductive Health Characteristics of Participants from Koja
Hospital (RSUD Koja), Cipto Mangunkusumo Hospital (RSCM), and
Tangerang Hospital (RSUD Tng)
Characteristic
RSUD Koja
n = 75 (%)
RSCM
n = 64 (%)
RSUD Tng
n = 90 (%)
using or have ever used implant
contraception
yes
no
no data
32 (42.7%)
42 (56.0%)
1 (1.3%)
29 (45.3%)
31 (48.4%)
4 (6.3%)
30 (33.3%)
50 (55.5%)
10 (11.2%)
period of using contraceptive
<1 year
1-2 year
>2 year
7 (21.7%)
8 (25.0%)
17 (53.3%)
8 (27.6%)
8 (27.6%)
13 (44.8%)
4 (13.3%)
7 (23.3%)
19 (63.4%)
Husband has ever had syphilis
yes
no
not answering/do not know
4 (5.4%)
63 (83.9%)
8 (10.7%)
0 (0.0%)
54 (84.4%)
10 (15.6%)
4 (4.4%)
85 (94.5%)
1 (1.1%)
Husband has ever had sex with
other woman
yes
no
10 (13.3%)
35 (46.7%)
30 (40.0%)
0 (0.0%)
48 (75.0%)
16 (25.0%)
1 (1.1%)
59 (65.6%)
26 (28.9%)
Husband has ever had sex with
female sex worker
yes
no
6 (8.0%)
41 (54.7%)
28 (37.4%)
1 (1.6%)
46 (71.8%)
17 (26.6%)
1 (1.1%)
6 (6.7%)
83 (92.2%)
participant has ever experienced
low abdominal pain
yes
no
no data
33 (44.0%)
41 (54.7%)
1 1.3%)
25 (39.0%)
32 (50.0%)
7 (11.0%)
82 (91.1%)
7 (7.7%)
1 (1.1%)
experiencing fluor albus
yes
no
59 (78.6%)
16 (21.3%)
51 (79.7%)
13 (20.3%)
85 (95.6%)
4 (4.4%)
Most patients from all three locations were already
married. Occupation-wise, the husbands were civil
servants or businessmen and wives were mostly
hosusewives at all three locations showing similar
proportions. In accordance with its location, many
patients at RSUD Koja were married to laborers/
drivers/seamen. Generally these professions are
thought to have high risks of acquiring sexually
transmitted diseases (STD )because of their frequency
of travelling far and long.
Utilizing IUD was known to increase women’s risk of
acquiring PID.12 Many of the participants had used
or were using IUD (RSUD Koja: 42,7%; RSCM 20,5%;
RSUD Tangerang: 33,3%) with the average wearing
duration of more than 2 years (see Table 1). However,
data in this study did not reveal a significant
correlation between IUD usage and PID (OR: 1,2; p
value: 0.65).
Many studies have shown that STD cause PID.5-8,12
From this study it was revealed that most participants
at these hospitals stated that both themselves and
their husbands had never had suppurative/purulent
discharge or syphilis. Only 5 (6.7%) amongst the
participants at RSUD Koja admitted to have had
syphilis. At that hospital 4 (5.4%) patients stated that
their husbands have had syphilis or purulent urethral
discharge. Several participants from that hospital also
admitted that their husbands have had sexual intercourse
with other women or sex workers (see Table 1).
PID is a disease that often becomes chronic or
it recurs.1 In fact many of these participants had
previously complained of lower abdominal pain.
At RSUD Tangerang it was more than 80%. That
hospital’s participants generally had this complain
for less than 1 year. This was different in RSCM, where
patients generally complained of lower abdominal
pain for > 2 years ago.
White discharge is also a symptom of PID.12 More
than 75% of patients also complained of fluor albus
when they came to the hospital (see Table 1).
The prevalence of gonorrhea amongst participants
with lower abdominal complaints ranged from 0-4%,
the highest figure found at RSUD Koja (see Table
2). The prevalence of chlamydia ranged from 6.79.4%, the highest figure at RS Cipto Mangunkusumo
(Table 2). Overall, the proportion of gonorrhea
and chlamydia amongst participants with lower
abdominal pain was 1.7% and 7.9%.
If the denominator is the number of PID patients,
Table 2. Proportion of Gonorrhea and Chlamydia among Participants
Who Complained of Low Abdominal Pain and among Patients with PID
Location
RSUD Koja
6
SPES
75
RSCM
64
RSUD Tng
90
Total
(% median)
229
GO(+)
(%)
3
(4%)
0
(0%)
1
(1.1%)
4
1.7%
Cla(+)
(%)
5
(6.7%)
6
(9.4%)
7
(7.7%)
18
7.9%
6
PRP (%)
55
(73.3%)
50
(78.1%)
82
(91.1%)
187
81.6%
GO(+)
(%)
3
(5.5%)
0
(0%)
1
(1.2%)
4
2.1%
Cla(+)
(%)
5
(6.7%)
6
(12%)
7
(8.5%)
18
9.6%
then the prevalence of gonorrhea at the three
hospitals ranged from 1.2-5.5% and Chlamydia from
6.7-12.0%. Overall, the prevalence of gonorrhea and
Chlamydia amongst PID patients are 2.1% and 9.6%
(Table 2).
There was no significant difference between the
gonorrhea-positives amongst the PID and non-PID
patients; but there was a difference between the
Chlamydia-positives amongst the PID and non-PID
patients.
The proportion of PID patients amongst participants
whose chief complaint was lower abdominal pain
15
Epidemiology & STI
Epidemiology & STI
6
6
Epidemiology & STI
ranged from 73.3-91.1%, found highest at RSUD
Tangerang. Overall, the proportion of PID is 81.6% (see
figure 1). Around half of the PID patients were given
short therapy in control
63
short therapy
89
79
standard therapy in control
95
standard therapy
PID case
187
229
Number of participant
0
50
100
150
200
250
Figure 1. PID Patients, Type of Therapy and Control Visit
Standard therapy: Doxycycline 2x100 mg/day for 14 days & Ciprofloxacine
500 mg single dose; Short therapy: Doxycycline 2x100 mg/day for 7 days &
Ciprofloxacine 500 mg single dose
standard regimen and the rest given short regimen,
randomly picked.
From 184 patients who were given standard- and shortregimens, 142 (77,2%) came back for followup: 114
(80,3%) were clinically declared to be fully recovered
and 28 (19,7%) were stated to have not yet or weren’t
fully healed. The details of the recovered patients
were as follows: 68/79 (86.1%) patients who received
standard regimens and 46/63 receiving short regimens.
Patients who were “lost” due to the lack of follow up
were 42: 16 (38.1%) received standard regimen and 26
(61.9%) received short regimen (see Chart 1).
significant with a p value: 0,005 (M-H), the difference
is very small.
If a patient who did not come back for follow up
were regarded as having recovered, then the result
was: a PID patient’s probability of recovery after
receiving standard-regimen is only 1.1 times more
than a patient given a short-regimen treatment.
This difference is statistically insignificant (p value:
0,16). Once again, this shows that the probability of
recovery after receiving standard regimen is equal to
when receiving short regimen.
On analyzing per hospital, at RSUD Koja: a PID
patient’s probability of recovery after receiving
standard-regimen was 1.2 times more than a
patient given a short-regimen, this difference was
statistically insignificant (p value: 0,59). A similar
result was also shown at RSUD Tangerang, where a
PID patient’s probability of recovery after receiving
standard-regimen was only 1.03 times higher than a
patient given a short-regimen, this difference being
statistically insignificant (p value: 0,72). However, it
was different for RS Cipto Mangunkusumo, where a
PID patient’s probability of recovery after receiving
standard-regimen was 1.8 times more than a
patient given a short-regimen, and this difference is
statistically significant (p value: 0,02).
80
70
Overall, among those with PID diagnosis, without
considering their Chlamydia status, the table
showing data of recovery on both treatment groups
is shown in Figure 2. Out of 79 patients who received
standard regimen and came back for followup, 68
(86,1%) were confirmed to have recovered clinically
(73%). The probability of someone to be recovered
after receiving a standard regimen is only 1.2 times
higher than if she were given a short regimen, and
statistically this difference is borderline (p value: 0,05
with confidence interval: 0,99-1,40).
11
60
17
50
40
30
68
48
20
10
0
standard therapy
short therapy
Cured
Not cured
Figure 2. Proportion of Cured Cases with Standard- and Short-therapy
among PID Patients in 3 Hospitals
Note: Lost of follow up is not counted
RR = 1.18 (0.99<RR<1.40); p value: 0.05 (Mantel-Haenszel)
6
Further Analysis
Seeing the large number of patients who didn’t
come back for follow up, efforts were made to
conduct several further analyses. According to the
conservative analysis, a PID patient’s probability of
recovery after receiving standard-regimen is only 1.4
times higher than a patient given a short-regiment
treatment. Although this risk-ratio is statistically
16
6 Participants: 229 persons
PID: 187 persons (81.6%)
Standard Therapy*: 79
Short Therapy*: 63
6
Cla(+)
Cla(-)
Cla(+)
Cla(-)
11
84
7
82
8
2*
60
9*
4
1*
42
16*
Not
Not
Not
Not
cured
cured
cured
cured
Cured
Cured
Cured
Cured
Chart 1. Number of PID Cases, Therapy, Lab Result, and Therapy Result
among PID Patients in 3 Hospitals
*those who did not return for control are excluded from the chart
Other
Therapy:
3
NonPID: 42
(18.4%)
When seen from the chlamydial status, it was shown
that if a person was infected with chlamydia, then
both the standard and short regimen groups didn’t
show a difference in recovery (RR = 0.9 with p value
0.72). Also, if someone has PID due to etiologies
other than Chlamydia, the recovery chance of one
who received a standard regimen is 1.2 times more
than one given a short regimen; this difference was
statistically significant (p value: 0,03).
From all patients who were gonorrhea-positive (4
people), 2 were clinically declared as recovered, 1 as
not recovered, (though the serial lab tests showed
a negative-gonorrhea result), and the remaining
1 didn’t come back for follow up. That patient who
affirmed to not having been recovered came from RS
Cipto Mangunkusumo. After four weeks during the
third GenProbe test, a recurrent gonorrhea-positive
result was presented. This implied a re-infection.
Among Chlamydia-positive patients (18 people), 12
were clinically declared as recovered. Among them 5
were re-tested with GenProbe, and the results were
negative. There were 3 who were clinically stated
as not recovered, 2 among them re-tested using
GenProbe with negative results. The remaining 3
patients didn’t come back; hence their recovery
progress could not be known.
Conclusions
From this results, it can be concluded that the
proportion of PID patients with lower abdominal
pain were at RSUD Tangerang (91.1%), whereas at
the other two hospitals the occurrence of lower
abdominal pain from 73-78%.
The main cause of PID at the three locations were nongonococcal and non-chlamydial. The proportion of
gonorrhea-positive PID patients were 2.1% (RSUD Koja
5,5%; RSCM 0%; RSUD Tangerang 1,2%). The proportion
of Chlamydia-positive PID patients were 9.6% (RSUD
Koja 6,7%; RSCM 12%; RSUD Tangerang 8,5%).
Based on literature, other etiologies of PID are
Mycoplasma hominis, Bacteroides spp or other
anaerobic bacteria, facultative bacteria such
as Haemophilus influenza, Garnerella vaginalis,
Escherichia coli, and Streptococcus spp.
There were no patients who had positive lag tests
for both Chlamydia and gonorrhea. The proportion
of gonorrhea amongst the PID and non-PID patients
was not significantly different, since the number was
very small. As for Chlamydia, its proportion among
PID and non-PID patients was significantly different.
It seems that the clinical diagnosis of PID was a good
prediction for chlamydial infection.
The recovery probability of a PID patient who
received a standard-regimen was only slightly better
than if she received a short-regimen (RR = 1.2). This
small difference even is borderline (p value: 0.05). If
those who didn’t come back for follow up are also
considered to not have been recovered, the standard
regimen shows a higher significance (RR = 1.4; p
value: 0.005). Analysis per hospital showed that at
RSUD Koja and RSUD Tangerang, patients given
standard regimen showed no significant difference
in recovery compared to short regimen. However
at RS Cipto Mangunkusumo patients who received
standard regimen showed almost a 2 times (1.8
times) better chance at recovery than those receiving
short regimen. From this study it was not possible to
determine the likely etiologies of these differences
between the three hospitals.
Recovery rates are not dependent on whether the
cause of PID was gonococcal or Chlamydia. PID
patients due to non-gonococcal and non-chlamydial
causes were also sensitive to ciprofloxacin therapy
500 mg (single dose) and doxycycline 100 mg twice
daily for 14 days. Especially for PID patients with
presence of Chlamydia, standard and short regimens
didn’t show different recovery rates (RR = 0.9; p value:
0.72). Besides, compliance in taking the medications
determined recovery rates. Patients who complied
well showed no difference in recovery between those
who took standard and short regimen (RR = 1.1; p
value: 0.41).
For patients who didn’t recover, possibility of
endometriosis or psychosomatic complaints must be
considered.
17
Epidemiology & STI
Analyzing the stratification based on compliance
of consuming medications showed that among
patients highly compliant to take medicines, then
there was no difference between those receiving
standard and short regimens (RR = 1,1 with p value:
0,41). This was also applied to when patients did not
comply, then there was no difference between those
receiving standard versus short regimens (RR = 2.2
with p value: 0.54).
Epidemiology & STI
Special Thanks
This research was conducted using RIS-BINKES 19981999 funds from HIV/AIDS Prevention Project (HAPP)Ditjen PPM-PLP Depkes RI in the form of GenProbe
tests. The writer thanks Dr. John Moran, DR. Rianto
Setiabudi, Prof. Loedin, and Dr. Ratna Budiarso for
their critique and comments; to Dr. Faisal Yatim, MPH,
Dra. Chatra Yona, Sri Sugianingsih, and Yudi Hartoyo
for their technical help; and to doctors, midwives,
and nurses at the three hospitals who facilitated the
course of this research.
Reference
1.
Meheus A. Women’s health: importance of reproductive tract
infections, pelvic inflammatory disease and cervical cancer.
In: Germain A, Holmes KK. Piot P, et al. RTI: Global Impact and
Priorities for Women’s Reproductive Health. New York, NY:
Plenum Press: 1992: 61-91.
2.
Sciarra JJ. Fertility and infertility: a global perspective. In:
Saifuddin AB, Affandi B, Wiknyosastro GH eds. Women’s Health:
Recent Advances in the Asia-Oceania Region. Jakarta, Yayasan
Bina Pustaka Sarwono Prawirohardja; 1995: 25-34.
3.
4.
Ha sibuan ER, Moegni EM. Infeksi tuba dan beberapa asp
ck lainnya pada kehamilan tuba terganggu. Makalab pada:
Pertemuan Tahunan Perkumpulan V POGI, Denpasar, 1988.
Sumapradja S. Studies on infertile couples in Jakarta.
Dissertation University of Indonesia. Jakarta, 1980.
18
5.
Wolner-Hanssen P. Clinical manifestations, diagnosis, and
therapy of acute pelvic inflammatory disease. STD bulletin
1990; 10(1): 3-10.
6.
Soper DE. Pelvic inflammatory disease: current
conceptschanging perspectives. STD bulletin 1992; 11(2):
3-11.
7.
Washington E, Berg AO. Preventing and managing pelvic
inflammatory disease: key questions, practices, and evidence.
The Journal of Family Practice 1996; 43(3)-,283-93,
8.
De Muylder X, Laga M, Tcnnstedt C, Van Dyck E, Aelbers GNM,
Not P. The role of Neisseria gonorrhoeac and Chlamydia
trachomatis in pelvic inflammatory disease and its sequalae
iu Zimbabwe. The Journal of Infectious Disease 1990; 162:
501-5.
9.
Wishnuwardhani SD. Penyidikan chlarnydia pada servisitis
den-an perneriksaan Pap smir dan E1isa. Tesis untuk Program
Studi Obstetri dan Ginekologi FKUI-RSCM, Jakarta, 1987.
10. Iskandar MB; Vickers C. lndrawati 5, Qomariyah 5N. 5impulan
laporan penelitian operasional pengendalian penyakit
menular seksual (PMS) melalui pelayanan KB di Jakarta Utara.
Dipresentasikan di Dep.Kes, Jakarta tanggal I Agustus 1997.
11. Sofyan 0. Survai penyebab lekore di poiiklinik obstetri dan
ginekologi RS Cipto Mangunkusumo. Tesis untuk Program
Studi Obstetri dan Ginekologi FKUI-RSCM, Jakarta, 1997.
12. Centers for Disease Control. Policy guidelines for the
prevention and management of Pelvic Inflammatory Disease
(PID). Atlanta: CDC, April, 1991.
13. Centers for Disease Control and Prevention. MMWR: Reports
and Recommendations. Atlanta, CDC: Maret 1998.
Translated from Validasi Pemeriksaan Infeksi Menular Seksual Secara Pendekatan Sindrom Pada Kelompok Wanita Berperilaku
Risiko Tinggi.
Eko Rahardjo1
Between Lutam1
Chatra Oktarina1
Sinurtina Sihombing1
Sjahrial Harun1
1
Bul. Penelit. Kesehat. 28 (3&4) 2000: pp460-72
19
Epidemiology & STI
Validation of Syndromic Approach for
the Management of Sexually Transmitted Infections
among Women with High Risk Behaviour
Abstract
Validation of The Syndromic Approach for The Management of Sexually Transmitted Infections
in Women With High Risk Behaviour
Accurate and adequate treatment of STIs is a critical component of STI-control activities to reduce transmission and sequelaes. On the other
hand, chronic shortage in skilled staff and laboratory equipment in many countries necessitate the use of clinical skills more in order to
diagnose and differentiate STIs. For these places, the WHO has recommended and produced a protocol of it syndromic approach management
of STIs in place of treatment by etiology. Since 1997 the Indonesia Ministry of Health has been conducting national training on this method
However, the syndromic approach for vaginal discharge is known to be problematic since differentiation among cervicitis, vaginitis, and even
normal condition is difficult.
The main objective of this study is to determine the sensitivity, specificity and positive predictive value of the syndromic approach
management of women with signs and/or symptoms of abnormal vaginal discharge. The sample population were women with high risk
sexual behaviors in East Java and North Sulawesi provinces. The laboratory tests using DNA hybridization probe technique (the PACE 2
test, Gen-Probe, San Diego, Calif) for Neisseria gonorrhoeae and Chlamydia trachomatis were used as gold standard. In addition, we also
compared the clinical approach widely used by clinicians (mainly at hospitals) with laboratory results.
A total of 439 participants was recruited purposively (230 from E. Java and 209 from N.Sulawesi). In E.Java, the sensitivity, specificity, and
predictive value of the syndromic management for vaginal discharge are 31%, 83%, and 59%, respectively, and in N. Sulawesi 49%, 56%,
and 40%, respectively. The clinical approach did not show better results. In E.Java the sensitivity, specificity, and positive predictive value
are 13%, 89%, and 50%, respectively, while in N.Sulawesi they are 4?%, 619 and 39%, respectively. As a conclusion, the current form of
syndromic management has little use for STI screening among high risk women. Further studies by adding more criteria to the syndromes
are needed to improve this method.
Key words: syndromic approach, sexually transmitted infections, Gen-Probe.
Introduction
Sexually transmitted infections (STI) are still a health
problem for the worldwide community,1 including
Indonesia.2,3 The need for an effective preventive
program increased ever since there was evidence
that STI was an independent risk factor for HIV
transmission. Diseases such as gonorrhea, chlamydia,
syphilis, and chancroid can increase the risk of HIV
transmission during sexual intercourse.4,5
The syndromic approach is a treatment for STI and
other reproductive tract infections (RTIs) that is
recommended by the WHO for developing countries
when laboratory facilities are not always available. STI
include trichomoniasis, gonorrhea, and chlamydia;
whereas RTIs include bacteriosis vaginalis (BV) and
candidiasis. Using the syndromic approach, diagnoses
are made based on complaints and signs (male
urethral discharge, vaginal discharge, genital ulcers,
female lower abdominal pain, scrotal swelling, genital
growth, and conjunctivitis/ophthalmia neonatorum),
as well as analysis of risk factors (>1 sexual partner
within the last month, sexual intercourse with a sex
worker within the last month, experienced one/more
episode(s) of STI within the last month, and history of
partner’s high-risk sexual behavior).6 Treatment given
is presumptive in nature – not having to wait for lab
results – and involve therapy of several infections
that are assumed to be the etiology (such as a patient
with vaginal discharge who receives treatment for
Chlamydia, gonorrhea, and trichomoniasis, and also
for RTIs such as candidiasis and BV).6
Along with that, since 1997, the Direktorat Jenderal
Pemberantasan Penyakit Menular dan Penyehatan
Lingkungan (Ditjen PPM-PL) has been conducting
national-scale trainings of syndromic management.6
Remembering that this method was currently
considered to be the most appropriate method
considering the situation in Indonesia and was likely
21
Epidemiology & STI
Validation of Syndromic Approach for
the Management of Sexually Transmitted Infections
among Women with High Risk Behaviour
Epidemiology & STI
to be continually used, it was necessary to compare
its effectiveness from time to time by using the
gold standards for comparison with the lab testing
(GenProbe for gonorrhea and Chlamydia, and direct
smear tests for trichomonas, candida, and BV).
Besides that, there is another treatment method
usually practiced by clinicians at hospitals. The
Clinical Approach is another STI/RTI treatment
by carefully observing the signs and symptoms
more than the Syndromic Approach. For example,
assessment is also given to consistency, color, and
odor of discharge. For women, speculums are used
to assess the conditions of the vagina, cervix, etc; and
– if necessary – an internal examination is performed.
The provisional diagnoses usually direct it towards
its etiology, such as candidiasis, trichomoniasis, BV
(in this study these three diseases will be classified
under vaginitis), and cervicitis (usually gonococcal or
non-gonococcal infections).
This validation study will produce sensitivity and
specificity values for the syndromic approach that is
applied to high-risk behavior women. The results will
be useful in popularising this approach in Indonesia.
Materials And Procedure
This study compared a diagnostic method with two
other methods. It was carried out at the experimental
locations of the Pemeriksaan IMS Berkala Ditjen PPMPL program, which were East Java and North Sulawesi
provinces, from September 1999 to March 2000. The
sample was 439 sex workers or other female workers
that were regarded as having high risks of acquiring
STI (bartenders, karaoke, etc). Sex workers who were
pregnant, undergoing vaginal bleeding, or were
suffering from cervical cancer were not enrolled as a
subject of this study.
The sample number was calculated based on the
prevalence of Chlamydia trachomatis amongst sex
workers in Surabaya and Manado, which ranged from
20-22%, assuming that the method used (syndrome
or clinical approach) possessed a sensitivity of
minimum 50%. To obtain a precision of + 15% with
95% confidence interval, a minimum sample of 384
was required.
Management and analysis of data were done using
the Epi-Info software .
22
Recruitment Process
Before being examined, prospective subjects received
explanations about this study, the advantages and
types of the tests that were to be carried out. From
each sex worker that agreed to become a subject, an
informed consent was asked for. Forms were given
to participants to fill in demographic data, and then
asked to enter the examination room.
Physical examination
On the first examination, the doctor/midwife who had
been trained of the Syndromic Approach asked for
complaints and assessed risk factors from the subjects.
After that they were inspected and palpated in the
lithotomy position (without speculum examination).
The doctor then deduced the diagnosis based on the
Syndromic Approach.
After the doctor left the room, a second doctor, who
was not trained with the Syndromic Approach, will
enter the room. He/she examines and diagnoses
clinically (with speculum). After the diagnosis was
made, the vaginal and cervical discharge was taken
for laboratory confirmation. Treatment was given free
of charge in accordance to the Syndromic Approach
treatment (presumptive medication that doesn’t
need to wait for lab results).6
Laboratory tests
Vaginal discharge was taken for Gram staining and
examined for clue cells (indicator of BV) and candida
(pseudohyphaes and/or blastospores). Discharge
from the posterior fornix was taken for a wet
preparation with NaCl 0,9% solution. They were then
directly checked for the existence of Trichomonas
vaginalis.
Direct examination of the preparations and
Gram staining are standard methods to diagnose
trichomonas and candida infections.8 However for
BV, the existence of clue cells alone is not sufficient.
The standard method is seeing 3 out of 4 of the
following signs and symptoms: a) white discharge that
covers the vaginal wall; b) clue cells on microscopic
examination; c) pH of the vagina >4,5; d) odor of
the vaginal discharge resembling that of rotten fish
before or after adding KOH 10%.8 In this study,
although the full criteria were not used, the existence
of clue cells by Gram staining was considered more
valid than diagnosis by the Syndromic Approach.
Results
difference was shown for educations stratas; East
Javanese subjects were generally graduates from
elementary school, whereas those from North
Sulawesi from high school.
A difference was also portrayed regarding marital
status. East Javanese subjects were mostly widowers
(>75%), while the North Sulawesian bartenders were
mostly either married (47,4%) or single (39,2%).
In this study, every subject at every location was
highly motivated to participate in the study. Thus,
not every subject presented with complaints or
signs: only 20% of East Javanese subjects and 46%
North Sulawesian subjects had minimum one
complaint (white discharge/pain during urination/
lower abdominal pain/vaginal bleeding/difficulty to
conceive) when examined (Table 2).
Table 2. Proportion of Symptoms among Participants
Examination of STI was carried out by syndrome
and clinical approaches, and specimens were taken
from 230 female sex workers in the Jember and
Tulungagung areas, East Java, as well as 209 female
sex workers and bartenders in Bitung and Mando
cities, North Sulawesi. Comparisons of several
characteristics between subjects from East Java and
North Sulawesi can be seen in Table 1.
The average age of the study subjects was the same
in both cities, which was 25 years old. The age range
in East Java (15-39 years old) was slightly smaller than
that in North Sulawesi (14-45 years old). A significant
Symptom
N
having symptom
fluor albus
feeling pain when urinate
lower abdominal pain
vaginal bleeding
feeling difficult to get
pregnant
East Java
230
46 (20%)
36 (15.7%)
15 (6.5%)
36 (15.7%)
2 (0.9%)
North Sulawesi
209
96 (46%)
56 (26.8%)
14 (6.7%)
26 (12.4%)
8 (3.8%)
17 (7.4%)
12 (5.7%)
During physical examination, 27,4% East Javanese
subjects and 47,8% North Sulawesian subjects in fact
presented with minimum one sign (white discharge,
vesicles on external genitalia/ulcers/erosions in the
vagina/vaginal warts).
With laboratory tests, the prevalence of several STIs
Table 1. Comparison of Socio-demographic Characteristics
of Participants from East Java
java and North Sulawesi
Characteristics
N
Work place
Age mean
age range
Education
no education
elementary school
junior high school
senior high school
academy/university
no data
Marital status
married
single
widow
no data
Number of Children
mean
range
East Java
230
100%
lokalisasi
North
Sulawesi
209
25 y.o
15-39 y.o
19% lokalisasi
81% bar
25 y.o
14-45 y.o
19 (8.3%)
102 (44.3%)
61 (26.5%)
34 (14.8%)
3 (1.3%)
11 (4.8%)
1 (0.5%)
31 (14.8%)
55 (26.3%)
102 (48.8%)
18 (8.6%)
2 (1%)
12 (5.2)
31 (13.5%)
176 (76.5%)
11 (4.8%)
99 (47.4%)
82 (39.2%)
26 (12.4%)
2 (1%)
1 child
0-4 children
1 child
0-6 children
Table 3. Proportion of Clinical Signs During Examination
Signs
N
fluor albus
vesicle on external genital
vaginal ulcer
Vaginal wards
East Java
230
46 (20%)
36 (15.7%)
15 (6.5%)
36 (15.7%)
North Sulawesi
209
96 (46%)
56 (26.8%)
14 (6.7%)
26 (12.4%)
and RTIs among these subjects was determined
(Table 4). In East Java a prevalence of T. vaginalis
of 7,4% was found, candidiasis 0,9%, BV 17,8%, N.
gonorrhoeae 38,7%, and C. trachomatis 16,1%.
While in North Sulawesi, a prevalence of T. vaginalis
of 17,7% was found, candidiasis 9,1%, BV 22,5%, N.
gonorrhoeae 23%, and C. trachomatis 24,9%.
The clinical diagnosis for STI/RTI that was attempted
23
Epidemiology & STI
Cervical discharge was taken testing with the GenProbe technique (PACE 2 test, San Diego, Calif.) for
Neisseria gonorrhoeae and Chlamydia trachomatis.
Because culture tests were not conducted, the GenProbe test was hence considered the gold standard.
Gen-Probe tests used chemiluminescent (shining
chemical substances) DNA probes . These probes
form hybrids with the 16s rRNA sequence from
Chlamydia. After the DNA-rRNA hybrid is formed,
it gets absorbed into the magnet beads and the
subsequent chemiluminescent reactions are
detected quantitatively by the luminometer. Besides
being practical, this test has a high sensitivity and
specificity compared to the gold-standard culture
test (sensitivity value for gonorrhea is around 93%;9
chlamydia ranges from 77-94%;10 and specificity
value for gonorrhea is 98%;9 chlamydia ranges from
96-100%10).
Epidemiology & STI
was cervicitis (cervical inflammation) and vaginitis
(vaginal inflammation). The proportion of cervicitis
was found to be 12,2% in East Java and 39,7% in
North Sulawesi; and vaginitis to be 15,2% in East Java
and 29,7% in North Sulawesi (Table 4).
The syndrome approach diagnosis for STI/RTI that
was attempted was vaginal discharge. Its proportion
less condition from each type of infection. In that
table the results from both areas are joined.
When the accuracy of clinical diagnosis was compared
to laboratory tests, a sensitivity value of less than 50%
was obtained. For cervicitis in East Java and North
Sulawesi, the sensitivity values obtained were 13,7%
and 42,3%; specificity 89,1% and 61,8%, while PPV
50% and 39,8% (Table 6).
Table 4. Proportion of T.vaginalis, Candidiasis, BV, N.Gonorrhea,
C.trachomatis, Clinical & Syndromic Diagnosis
230
17 (7.4%)
16 (7.0%)
2 (0.9%)
41 (17.8%)
North
Sulawesi
209
96 (46%)
56 (26.8%)
14 (6.7%)
26 (12.4%)
54 (23.5%)
89 (38.7%)
37 (16.1%)
102 (44.3%)
89 (42.6%)
48 (23.0%)
52 (24.9%)
78 (37.3%)
vaginitis
cervicitis
35 (15.2%)
28 (12.2%)
62 (29.7%)
83 (39.7%)
Syndromic Diagnosis
6 discharge
vaginal
lower abdominal pain
54 (23.8%)
23 (10%)
96 (46%)
8 (3.8%)
East Java
6 Study Object/Specimen
Trichomonas vaginalis
Diplococcus gram (-) (intra-extra)
Candidiasis
Clue cell (Bacterial Vaginosis)
T. vaginalis and/or candidiasis and/or
BV
N. gonorrhea (Gen-Probe)
C. trachomatis (Gen-Probe)
N. gonorrhea and/or C. trachomatis
Clinical Diagnosis
STI: T.vaginalis, N.Gonorrhea, and C.trachomatis
was found to be 23,8% in East Java and 46% in North
Sulawesi (see Table 4). These diagnoses in East Java
were made by midwives and in North Sulawesi by
general practitioners, both having trained of the
Syndrome Approach method.
On analysis, the accuracy of diagnosis of vaginal
discharge obtained using the syndromic
approach was compared to Gen-Probe lab
results (for gonorrhea and Chlamydia), and
other lab tests (for BV, trichomoniasis, and
candidiasis). The syndromic approach also, in
fact, produced low sensitivity values (East Java
31,4% and 35,2%; North Sulawesi 48,7% and
53,9%), moderate specificities (East Java 82,8%
and 80,1%; North Sulawesi 55,7% and 60%),
and low PPVs (East Java 59,2% and 35,2%; North
Sulawesi 29,6% and 50%) (Table 7).
Discussion
Although diagnosis of STI using laboratory tests
is the ideal way, it has several main weaknesses. High
costs, both initially and for maintenance makes it less
Table 6. Clinical Diagnosis
Diagnose Accuracy Compared
Compare to Lab Result in
East Java and North Sulawesi
It has been known that STI among women more
often presented without symptoms or signs. Table 5
portrays the proportion of symptom-less and signTable 5. Other STIs & RTIs without Signs and Symptoms
among Female Sex workers/Bar Workers in East Java and
North Sulawesi
Trichomoniasis
no symptom
no sign
N
(Proportion)
54
30 (55.6%)
27 (50%)
Candidiasis
no symptom
no sign
21
11 (52.4%)
8 (38.1%)
BV
no symptom
no sign
88
67 (76.1%)
50 (56.8%)
Gonorrhea
no symptom
no sign
135
86 (63.7%)
82 (60.7%)
Chlamydia
no symptom
no sign
89
58 (65.2%)
54 (60.7%)
Infection
24
sensitivity
specificity
PPV
NPV
p value
RR
Clinical Diagnose:
Cervicitis
Clinical Diagnose:
Vaginitis
gonorrhea & chlamydia
candida and/or
trichomonas and/or BV
E. Java
P: 44.3%
13.7%
89.1%
50%
56.4%
>0.05
1.3
N. Sulawesi
P: 37.3%
42.3%
61.8%
39.8%
64.3%
>0.05
1.1
E. Java
P: 23.5%
29.6%
89.2%
45.7%
80.5%
<0.05
2.7
N. Sulawesi
P: 42.6%
35.9%
75%
51.6%
61.2%
>0.05
1.4
Table 7. Syndromic Diagnose
Compare to Lab Result in
Diagnosis Accuracy Compared
East Java and North Sulawesi
SyndromicDiagnosis
Diagnose: Vaginal Discharged
Syndromic
gonorrhea & chlamydia
sensitivity
specificity
PPV
NPV
p value
RR
E. Java
P: 44.3%
31.4%
82.8%
59%
60.2%
<0.05
1.8
N. Sulawesi
P: 37.3%
48.7%
55.7%
39.6%
64.6%
>0.05
1.1
candida and/or
trichomonas and/or BV
E. Java
P: 23.5%
35.2%
80.1%
35.2%
80.1%
<0.05
1.8
N. Sulawesi
P: 42.6%
53.9%
60%
50%
63.7%
>0.05
1.4
In this study, Gen-Probe test was used as a gold
standard for detecting N. gonorrhoeae and C.
trachomatis. Other RTIs (trichomoniasis, candidiasis,
and BV) were checked by direct examination and
staining. The clinical diagnosis, which doesn’t need
many additional fees besides the basic Puskesmas
examination tools, was also used as a comparison.
Generally a difference was found regarding
characteristics of education strata and marital
status between East Javanese and North Sulawesian
subjects. The widower status of most female sex
workers in East Java was also found at former
locations of Kramat Tunggak, Jakarta,11 and Kupang.12
However, the East Javanese subjects were truly from
those locations and not bartenders like in North
Sulawesi, thus having a possibility of bias.
Due to this study’s attempt to involve the entire
population at each research location (examination
by screening), only a small percentage of female
sex workers or bartenders stated their complaints
(see Table 2). Regardless of whether the subject felt
a symptom or not, clinically several abnormal signs
were found on most subjects (Table 3).
The prevalence of gonorrhea and Chlamydia in East
Java (Jember and Tulungagung areas) in this study
was not far different from a similar STI prevalence
amongst the female sex workers in Surabaya (East Java)
in 1998.13 At that time they obtained a prevalence for
gonorrhea of 32% (this study: 38,7%) and Chlamydia
20% (this study: 16,1%). Whereas in North Sulawesi,
compared to studies done at female sex worker areas
and bars in Manado in 1998, only gonorrhea showed
a significant difference (6% in 1998 and 23% in 2000);
while Chlamydia showed an insignificant difference
(22% in 1998 and 29% in 2000).13 This 15-30% range is
consistent enough with the prevalence of gonorrhea
and Chlamydia among female sex workers at other
locations in Indonesia.12,14
Besides those two STI above, the prevalence of
trichomonas in East Java in this study (7,4%) and
in the 1998 study (5%) also showed a very small
difference compared to a study by AusAID (4,9%).12
These results strengthens our knowledge that STI
among women are often without symptoms and
signs.1,12 If analyzed per type of infection, it will
show that >60% of gonorrheal and/or chlamydial
infections present without signs/symptoms (Table 5).
Unfortunate, since these two STIs can cause severe
complications, such as pelvic inflammatory disease,
chronic pain, and infertility.1
In this study a quite large difference was found
regarding the proportion of syndrome-approach
diagnosis between East Java and North Sulawesi. The
skill and experience of the examiner plays a big role.
From further analysis it showed that the examiners at
North Sulawesi (doctors) produced diagnoses which
are slightly more sensitive but less specific compared
to those at East Java (midwives) (Table 7).
Both in East Java and North Sulawesi, the subjects were
also examined and clinically diagnosed by one or two
experienced general practitioner(s). Clinical diagnosis
for STI/RTI which were studied further into were
cervisitis (cervix inflammation) and vaginitis (vaginal
inflammation). Cervisitis can be caused by gonorrhea
and/or Chlamydia; whereas vaginitis can be caused by
trichomonas or candida or BV. Clinical diagnoses were
made based on anamnesis, observation with speculum,
palpation, the smelling sense, and (if needed) internal
examination. Hence, it was a conclusion from a group
of signs and symptoms.
In comparison between clinical diagnosis (cervisitis
and vaginitis) and laboratory testing, it was shown
that clinically diagnosis cervisitis and vaginitis had low
validities (Table 6). The knowledge and experience o f
the clinicians in fact played huge parts in these cases.
In addition to that, clinical examination could not be a
predictor for the existence of STI, since its PPV value is
only approximately half of what it assesses as positive.
As stated in the previous Materials and Procedure
section, the existence of clue cells on Gram staining
25
Epidemiology & STI
feasible in developing countries. On the other hand,
the Syndromic Approach doesn’t require additional
fees outside of the basic tools already possessed
by a primary health care centre (Puskesmas).
Unfortunately, this relatively easy method in fact
has weaknesses in terms of sensitivity, specificity,
and positive predictive value (PPV), especially when
applied to women.8 Thus, from time to time and
from one location to another, a validation procedure
needs to be carried out.
Epidemiology & STI
alone is not the standard way to diagnose BV. This
study intentionally didn’t include the other 3 criteria,
since it would have meant for the combination
of clinical recognition and laboratorium (though
in daily practice, this very combination of clinical
recognition and lab is the real ideal practice). Thus,
though the existence of clue cells is more specific
than diagnosing vaginal discharge, Gram staining
remained inaccurate as a determination of sensitivity
and specificity of other BV diagnostic methods. This
implies a careful interpretation of the sensitivityspecificity parts on Table 6 and 7.
Considering that vaginal infections are less dangerous
compared to cervical infections, the effect is not
that big for the patient if the treatment of vaginitis
is missed. A different issue applies with cervical
infections, which can cause serious complications.
This study results are slightly different from those
obtained from a STI prevalence study in East Nusa
Tenggara, Bali, and South Sulawesi by AusAID
(1999-2000).12 That study obtained sensitivity and
specificity values of diagnosing cervicitis in East Nusa
Tenggara of 46% 64%, compared to the lab results on
gonorrhea and/or Chlamydia. Even so, with PPV and
NPV values above 50%, clinical diagnosis of cervicitis
is an adequate indicator both for gonococcal and/or
chlamydial infections.
In the NTT study, clinical diagnosis of vaginitis showed
a lower validity value compared to cervicitis.12 In
that study, culture tests were used for trichomonas,
whereas staining tests where used for BV and
candida.
Diagnoses based on the syndromic approach, which
in this case was vaginal discharge, actually showed
sensitivity and PPV values <50% or a little over 50%
(Table 7). Whereas for NPV, the value ranged from 4060%. Seen from the OR and p values, vaginal discharge
turned out not to be a precise indicator for estimating
lab results for chlamydial and/or gonococcal STIs, as
well as BV/candida/trichomonas.
This study results are consistent with the results from
another study conducted among female sex workers
in East Nusa Tenggara by AusAID.12 That study had
found a very small sensitivity (4%) and PPV of 35,7%
from the existence of white discharge compared
to lab results. The white discharge complaint was
26
actually a bad indicator for estimating the existence
of gonococcal and/or chlamydial infections.
If treatment is given based on clinical and syndromic
approach, it might lead to over-treatment, meaning
treating someone who actually doesn’t suffer from an
STI/RTI, and under-treatment, meaning not treating
someone suffering from an infection. An example
of cervical infection (gonorrhea and/or Chlamydia)
in East Java (see table 6): its prevalence was 44,3%,
meaning that there were 102 female sex workers who
suffered from minimum one type of cervical infection.
By using the clinical method, 28 cases can be treated.
But from these 28 people, only 14 are truly infected,
the remaining 14 are over-treated. Conversely, from
the 202 people declared as healthy, in fact 88 people
suffered from gonorrhea and/or Chlamydia and are
missed from treatment.
In addition, using the Syndromic Approach, 54
people are treated (Table 7); though actually infected
are only 40 people, and the remaining 14 are overtreated (they are not ill). Conversely, from the 176
people declared as healthy, 82 are actually infected.
The mistake of over-treatment can still be tolerated,
since the harm it causes is only a waste of medicines.
But the second mistake implies more severe effects,
since it would mean that the clinical and syndromic
approach methods are not effective enough to break
the chain of STI/RTI.
In this study the subjects were taken from limited
locations, which were female sex workers and
bartenders from several cities in the East Java and
North Sulawesi provinces. Hence, we must be careful
when generalizing these results to the female sex
worker community all over East Java and North
Sulawesi.
Conclusions And Suggestions
1. The prevalence of STI/RTI amongst high-risk
women at several areas in East Java and North
Sulawesi are not significantly different compared
to the prevalence of STI/RTI amongst high-risk
women at other places in Indonesia.
2. Compared to the prevalence study done amongst
high-risk women in East Java and North Sulawesi
in 1998, the prevalence of STI/RTI in 2000 is
not much different, there is even an increase
(gonorrhea in Manado). This shows that there
help during the completion of this study. We also
thank the female sex workers and bartenders at the
research locations for their participation. To HAPP,
we thank you for your technical help and providing
lab materials/tools. Lastly, we thank our friends at
Puslitbang laboratory of Pemberantasan Penyakit for
your help in examining the specimens.
Reference
1.
Wasserheit JN. (1989). The significance and scope of
reproductive tract infections among third world women. Int.
J. Gynecol. Obstet., Supp1.3:145-168.
2.
Van der Sterren A, Murray A, Hull T. (1995). A history of sexually
transmitted diseases in the Indonesian archipelago since
1811. Working Paper on Demography. Australian National
University, Canberra.
3.
Iskandar MB, Vickers C, Indrawati S, Qomariyah SN. (1997).
Report on the STD control through Family Planning Clinics
in Northern Jakarta. Presented in the Indonesia Ministry of
Health, Jakarta.
4.
Pepin J, Plummer FA, Brunham RC, Piot P, Cameron DW, Ronald
AR. (1989). The interaction of HIV infection and other sexually
transmitted diseases: an opportunity for intervention. AIDS,
3:3-9.
5.
Weir SS, Feldblum PJ, Roddy RE, Zekeng L. (1994). Gonorrhea
as a risk factor for HIV acquisition. AIDS, 8: 1605-1608.
1. The syndromic approach should not be used
for screening STI/RTI among high-risk women. If
treating STI/RTI using this syndromic approach
has still to be used among high-risk women, a
validation should be made from time to time and
the examiners’ competence should be monitored
periodically.
2. A study and analysis of various other algorithms is
needed to be conducted in order to increase the
validity of the syndromic approach for STI/RTI,
for example by combining with other indicators
such as rapid tests, polymorphonuclear counts,
age, etc.
3. An analysis of the costs of accurate treatments
of the three mentioned methods above should
be conducted as an alternative evaluation on
considering which method should be adopted
by the national program.
6.
Departemen Kesehatan RI, Direktorat Jenderal PPM & PLP.
(1997). Penatalaksanaan penderita penyakit menular seksual
(PMS) dengan pendekatan sindrom: Buku pedoman interaktif.
Jakarta.
7.
Lwanga SK, Lemeshow S. (1991). Sample size determination in
health studies: A practical manual. WHO, Geneva.
8.
US Department of Health and Human Services, Centers for
Disease Control and Prevention (1998). 1998 Guidelines for
treatment of sexually transmitted diseases. Atlanta, Georgia.
9.
Koumans EH, Johnson RE, Knapp JS, St. Louis ME. (1998).
Laboratory tesiting for Neisseria gonorrhoeae by recently
introduced nonculture tests: A performance review with
clinical and public health consideration. Clinical Infectious
Diseases, 27:1171-80.
Special Thanks
13. Sedyaningsih-Mamahit ER, Rahardjo E. (1998). Hasil pretesting pemeriksaan PMS berkala pada kelompok risiko tinggi
di Jawa Timur dan Sulawesi Utara. Presentasi pada Pertemuan
HAPP-Ditjen P2M-PLP, Bogor, 911 Desember.
Recommendations
The research team offers gratitude to the Head
Kanwil Depkes Propinsi Jawa Timur and Sulawesi
Utara along with the entire staff, Head of BLK
Surabaya and Manado along with the staff, Head of
Dinas Kesehatan Kabupaten Tulungagung, Jember
and staff, Head of Dinas Kesehatan Kodya Manado
and Kota Bintung along with the staff, as well as Head
and staff of all involved Puskesmas, or all support and
10. Black CM. (1997). Current methods of laboratory diagnosis
of Chlamydia trachomatis infections. Clinical Microbiology
Reviews, 160-184.
Il.
Sedyaningsih-Mamahit ER. (1999). Female commercial sex
workers in Kramat Tunggak, Indonesia. Social Science and
Medicine, 49 (8): 1101-1114.
12. Partohudoyo S, Davies S. (2000). Hasil penelitian studi
prevalensi PMS di NTT, Bali dan Sulsel. Draft laporan untuk
Indonesia HIV/AIDS & STD Prevention and Care Project pada
Pertemuan anggota KPA, Jakarta, 25 Mei.
14. Kaldor J, Sadjimin T, Hadisaputro S. (1999). HIV/AIDS, STDs
and related risk behaviour in Indonesia: Report of a consensus
workshop.Golden Hotel, Jakarta 27-28 September.
27
Epidemiology & STI
is yet no impact of interventions. Besides that,
this can also be caused by the rapid exchange in
female sex workers/bartenders.
3. The syndromic approach without speculum can
not be used for STI/RTI screening purposes among
high-risk women. This method, besides causing
waste of medicine prescriptions (treating those
who do not need it), is ineffective for breaking
the chain of STI/RTI transmission (those infected
can be missed out on detection and treatment).
4. Clinical diagnosis of cervicitis or vaginitis is
also not adequate to estimate the presence of
a gonococcal and/or chlamydial infection in
the cervix, as well as candida/trichomonas/BV
infections. In this case, knowledge and skills of
clinicians have high influence on the results.
5. The study subjects are female sex workers and
bartenders who were taken from limited places;
hence we should be careful when generalizing
these results.
MR Joesoef MD1
M Gultom MD2
I D Irana MD3
J S Lewis MS1
J SMoran MD1
T Muhaimin MD3
C A Ryan MD1
1
Division of STD Prevention Prevention, Centers for Disease Control and
Prevention, MS-E04, 1600 Clifton Road NE, Atlanta, GA 30333, USA.
2
HIV/AIDS Prevention Project, Jakarta.
3
Indonesian Public Health Association (IAKMI), Jakarta, Indonesia.
Int J STD AIDS. 2003; Sep; 14(9):609–13
Royal Society of Medicine Services
29
Epidemiology & STI
High rates of sexually transmitted diseases among
male transvestites in Jakarta, Indonesia
Abstract
Many male transvestites (waria) in Jakarta, Indonesia engage in unprotected receptive anal and oral intercourse with homosexual and bisexual
men for pay. Although this behaviour clearly puts them at risk of sexually transmitted diseases (STDs), including HIV infection, little is known
about the prevalence of STD among them. To learn the STD prevalence and its risk factors, we conducted an STD prevalence survey among
waria in North Jakarta, Indonesia. From August to December 1999 we offered screening for rectal and pharyngeal infections with Neisseria
gonorrhoeae (Ng), Chlamydia trachomatis (Ct) by DNA probe (GenProbe PACE 2) and for Treponema pallidum (Tp) by non-treponemal and
treponemal serological tests. Of 296 participants (median age 28 years), 93% reported having been paid for sex. A total of 96% reported having
had oral sex (median three times/week) and/or anal sex (median three times/week) in the last week. Ng was found in the rectum of 12.8% and
the pharynx of 4.2%; Ct was found in 3.8% and 2.4%, respectively. A total of 43.6% had reactive non-treponemal and treponemal tests. Of the
129 with positive treponemal tests, 42.6% had non-treponemal test titres greater than 1:8. In the logistic regression model, waria who were
younger (≤25 years old) had a signi® cantly 3.5 times risk of Ng and/or Ct infections than older waria (>25 years old). Because only 12% of waria
stated that they consistently used condoms during any sex act, it is important to warn them that STD/HIV transmission can occur with either anal
or oral sex and that the risk of either anal or oral transmission can be reduced by condom use. In addition, high rates of asymptomatic syphilis and
rectal gonorrhoea warrant a periodic screening and treatment for these infections in this population. Because waria have the highest rates of HIV
and their clients consist of homosexual and bisexual men, successful prevention efforts in waria could help curb the spread of the epidemic.
Introduction
Methods
According to UNAIDS/WHO, Indonesia is considered
a country with a low-level HIV epidemic1. A low
epidemic is defined as a low prevalence of HIV in
high-risk populations (51%)1,2. However, in Jakarta,
Indonesia male transvestites (waria) have the highest
level of HIV prevalence (6%) among groups studied
to date2. Previous studies have also shown high rates
of HIV in transvestite population in other countries3–5.
In the Dominican Republic, male transvestites had
the highest level of HIV prevalence (34.4%) when
compared to homosexual, gigolo, or bisexual men3. In
Rio de Janeiro, Brazil, 64% of transvestite sex workers
were HIV positive4, and in Asunción, Paraguay, 27% of
male transvestite sex workers were HIV positive5.
The study population consisted of 296 warias who
were mostly recruited from North Jakarta (an estimated
400 warias live in North Jakarta). We established a
clinic in North Jakarta specifically to serve waria. From
August to December 1999, we invited waria (whether
symptomatic or not) to this clinic for free primary health
care services and health education. Of the 323 warias
recruited, 27 refused to participate in this survey. The
Institutional Review Board at the Centers for Disease
Control and Prevention and the Ethics Committee at
the Indonesia Ministry of Health approved this survey.
In Indonesian society, the role of waria as entertainers
goes far back to the 12th century of Hinduism
kingdom. During that time, the waria were revered
as singers, dancers, and comedians entertaining
the nobles. In the modern time, waria’s occupation
extended beyond entertainment to hairdressers,
beauticians, and sex workers. Many waria in Jakarta,
Indonesia engage in unprotected receptive anal and
oral intercourse with homosexual and bisexual men
for pay. Although this behaviour clearly puts them
at risk of HIV/STD infection, little is known about
the prevalence of STD and its sexual risk behaviour,
especially among those who live close to the harbour
north of Jakarta. Because STD can be used as an
indicator for high-risk behaviour and behavioural
information directs the provision of services, we
conducted a survey of STD and its associated risk
factors among waria in north Jakarta.
A team of outreach workers who worked closely with
waria, recruited waria for the survey and explained and
obtained consent for participation. Trained interviewers
administered the questionnaires at the clinic in the form
of multiple choice and open-ended questions. This
questionnaire consisted of questions on demographic
and socioeconomic characteristics (age, birth place,
education, working as sex worker, and fee per sex act),
sexual behaviour characteristics (age at first sexual
intercourse, age at first paid intercourse, duration in
commercial sex industry, and frequency of oral or
anal sex in the last week), and condom use (ever used
condom, frequency of condom use in the last month
with steady partners or clients).
At the clinic, a team consisting of a dermatovenereologist, a nurse, and a laboratory technician
examined participants and collected specimens. The
examination included genital, rectal, perianal, and
oropharyngeal examinations for ulcers, warts, and
discharges. Participants were tested for rectal and
31
Epidemiology & STI
High rates of sexually transmitted diseases among
male transvestites in Jakarta, Indonesia
Epidemiology & STI
pharyngeal infections with Neisseria gonorrhoeae (Ng)
and Chlamydia trachomatis (Ct) by DNA hybridization
probe (GenProbe PACE 2, San Diego, CA, USA) and for
Treponema pallidum (Tp) by RPR (rapid plasma reagin)
non-treponemal (Becton Dickinson Microbiology
System, MD, USA) and treponemal (Determine, Abbott
Laboratories, IL, USA) serological tests. We also collected
specimens from the urethra, rectum, and pharynx for Ng
culture. Because of problems with contamination, we
did not include the results of Ng culture in the analysis.
We used the following statistical analyses: Chisquare
or exact test for univariate analysis and logistic
regression model for multivariable analysis treating
infections of gonorrhoea and/or chlamydia and syphilis
seroreactivity (seroreactivity for treponemal test and
RPR titre > 1:8) as separate response variables. In our
analysis, we separated the infections of gonorrhoea
and chlamydia for syphilis seroreactivity because the
gonorrhoea and chlamydia infections reflected current
infections while the syphilis seroreactivity reflected
both current and past (inadequately treated) infections.
We adjusted the logistic regression analysis with sociodemographic variables (age, level of education) and
known risk factors of STD (frequency of oral and/or anal
sex and use of condom). Because most warias engaged
in both oral and anal sex, we were unable to separate
waria who used only oral or anal sex in the last week.
We also computed the odds ratios (ORs) with their 95%
confidence intervals (95% CIs).
Results
Most warias were young, had a low-income and
originated from outside of Jakarta (Table 1). About onethird had equal or less than elementary education. A
total of 41.9% had steady partners. Of those with steady
partners, only 12.1% always used condoms with steady
partners in the last month. Only 11.6% reported always
using condoms with clients in the last month. Almost
all warias (93.2%) worked as sex workers. They started
having intercourse early (median age of 15 years) and
working as sex workers at a young age (median age
of 18 years). Of those who reported sexual activities in
the last week, 94.4% had both oral and anal sex. The
prevalence of syphilis seroreactivity (seroreactivity for
both RPR and treponemal tests) was very high (43.6%)
(Table 2). Of those with syphilis seroreactivity, 42.6%
had RPR titres greater than 1:8. Of six warias with ulcers,
five warias had syphilis seroreactivity. Of those with
syphilis seroreactivity, 60.5% reported never having
had any ulcers. The prevalence of gonorrhoea was
also high, especially in the rectum (12.8%). Of those
with rectal gonorrhoea, 91.9% did not report anorectal
symptoms (pain during intercourse or rectal discharge).
The prevalence of rectal chlamydia was 3.8%. Of
32
those with rectal chlamydia infections, none reported
anorectal symptoms (pain during intercourse or rectal
discharge). The prevalence rate of rectal infection
was higher than pharyngeal infection. The combined
prevalence of rectal and pharyngeal gonorrhoea and/
or chlamydia infections was 18.3% and was similar by
level of education, frequency of sex in the last week,
median fee per sex act (data not shown), and frequency
of condom use with clients in the last month (Table 3).
In the logestic regression analysis, we found that warias
equal or younger than 25 years old had a 3.5 times
higher risk of gonorrhoea and/or chlamydia infections
than those older than 25 years (Table 3). In contrast,
syphilis seroreactivity (seroreactivity for treponemal
test and RPR titre 41:8) was less common among
young waria–13.8% in waria equal or younger than 25
years old and 21.7% in waria older than 25 years old;
an adjusted odds ratio of 0.5. Warias who engaged in
sexual intercourse more than four times a week had a
2.2 higher risk of syphilis seroreactivity than those who
had sex equal or less than four times per week.
Table 1. Selected socio-demographic characteristics
and sexual behaviours of waria in Jakarta, Indonesia
Characteristics
Median age—years
Born in Jakarta
≤ Elementary school education
Has a steady partner
Worked as sex worker
Median age at first intercourse—years
Median age at first paid intercourse—years
Median duration of paid sex—years
Had oral sex in the last week
Median frequency of oral intercourse/week
Had anal sex in the last week
Median frequency of anal intercourse/week
Median fee per sex act—US$
Ever used condom
Used condom in the last month with steady
partner
Always
Often
Seldom
Sometimes
Never
Used condom in the last month with clients
Always
Often
Seldom
Sometimes
Never
% (n)
28
19.0 (56)
39.2 (116)
41.9 (124)
93.2 (276)
15
18
9
96.2 (202)
5
96.1 (199)
3
1.25
67.6 (200)
12.1 (15)
6.5 (8)
12.9 (16)
12.9 (16)
55.7 (69)
11.6 (32)
12.7 (35)
19.9 (55)
12.7 (35)
43.1 (119)
Prevalence
Gonorrhoea
Rectum
Pharynx
Either
Chlamydia
Rectum
Pharynx
Either
Syphilis serologic reactivity*
RPR
1:2
1:4
1:8
>1:8
% (n)
12.8 (37)
4.2 (12)
15.9 (46)
3.8 (11)
2.4 (7)
6.2 (18)
43.6 (129)
16.3 (21)
28.7 (37)
28.7 (37)
42.6 (55)
*Seroreactivity for both rapid plasma reagin (RPR) and
treponemal test
Discussion
Most warias reported frequent, unprotected anal
and oral sexual intercourse for pay. The prevalence
of syphilis serologic reactivity was very high and
infections with gonorrhoea and/or chlamydia were
high. Daili et al. in 1998 also reported high rates of
syphilis serologic reactivity (67.9%) and pharyngeal
infections of gonorrhoea (19.2%) and chlamydia
(10.3%) among warias from east and centre of
Jakarta6. The higher rates in the study of Daili might be
due to differences in study population. In the present
study, we recruited waria from the community and
referred them to a general clinic setting while Daili
recruited waria at an STD clinic setting. It is possible
that recruitment and referral to the general clinic
setting might attract more asymptomatic waria
than recruitment at the STD clinic setting. The Daili
study reported that 28% of waria had symptoms
(pain during intercourse) while only 5% of the waria
The high proportion of asymptomatic carriers
represents a public health problem that could be
addressed by a screening programme. However,
for a screening programme to be cost-effective the
prevalence of the morbidity should be sufficiently
high and cost of the laboratory testing should be low.
In this population, syphilis seroreactivity and rectal
gonorrhoea infection were sufficiently high (43.6%
and 12.8%, respectively) and the laboratory tests for
detecting these morbidities are relatively simple and
inexpensive. RPR test is simple and inexpensive and
GenProbe testing for rectal gonorrhoea is relatively
simpler and less expensive than culture (GenProbe
testing can be batched for high volume; ideal for
Table 3. Percentage of waria with Ng/Ct*, syphilis and their odds ratios by selected characteristics
Ng/Ct*
Characteristics
Age(inyears)
≤25
>25
Education
≤Elementary
Junior school
≥High school
Frequency of sex last week
0 to 4/week
44/week
Condom use last month with clients
Often to always
Seldom to never
%(n)
Syphilis
Adjusted
oddsratios(95%CI)
%(n)
Adjusted
oddsratios(95%CI)
29.2 (113)
11.4 (176)
3.5 (1.7–7.0)
1.0 (—)
13.8 (116)
21.7 (180)
0.5 (0.3–1.1)
1.0 (—)
16.5 (115)
16.1 (81)
22.6 (93)
1.0 (—)
0.7 (0.3–1.7)
1.2 (0.5–2.6)
21.6 (116)
20.9 (86)
12.8 (94)
1.0 (—)
1.2 (0.5–2.7)
0.5 (0.2–1.3)
18.7 (139)
24.3 (103)
1.0 (—)
1.3 (0.6–2.5)
14.9 (141)
25.2 (107)
1.0 (—)
2.2 (1.1–4.3)
18.3 (120)
19.5 (1490)
1.0 (—)
1.3 (0.7–2.6)
18.9 (122)
19.5 (154)
1.0 (—)
1.3 (0.8–2.3)
* Includes rectal and/or pharynx infections of gonorrhoea and chlamydia
Includes seroreactivity for treponemal test and rapid plasma reagin titre 41:8
Adjusted for other characteristics in the table
Reference group
33
Epidemiology & STI
in the present study had symptoms (pain during
intercourse). We are not aware of other published
gonorrhoea or chlamydia prevalence among male
transvestites elsewhere. Among homosexual men,
gonorrhoea infections in the rectum and pharynx
are often asymptomatic7,8. Merino et al. reported that
66% of anorectal gonorrhoea and 89% of pharyngeal
gonorrhoea were asymptomatic7. Janda et al.
reported that 62% of anorectal gonorrhoea and 89%
of oropharyngeal gonorrhoea were asymptomatic8.
In the present study, we found that 92% of waria
with rectal gonorrhoea and 100% of waria with rectal
chlamydia were asymptomatic. Because we did not
ask waria about symptoms related to pharyngeal
infections, we do not know the proportion of waria
with asymptomatic pharyngeal infections. We
expect this proportion was high as well. We found
that among waria with syphilis seroreactivity, a high
proportion of them (60.5%) reported never having
had any ulcers.
Table 2. Prevalence of STD by site among waria in
Jakarta, Indonesia
Epidemiology & STI
a screening programme). In addition, Lewis et al.
have shown that GenProbe testing for rectal and
pharyngeal gonorrhoea is as good as culture9. In
summary, our findings underscore the importance
of periodic syphilis and rectal gonorrhoea screening
and treatment as parts of the prevention efforts.
The finding that the risk of current gonorrhoea and/or
chlamydia infections was 3.5 times greater in younger
waria was consistent with the findings of another
study among men in South Carolina, USA10. We did
not find any published studies on the relationship
between age and gonorrhoea/chlamydia among
male transvestites.
In contrast to gonorrhoea and/or chlamydia
infections, we found a higher prevalence of syphilis
seroreactivity in older waria than younger waria.
However, this increased prevalence of seroreactivity
in older waria reflects both past and current
infections. For current syphilis infection, a study
by Lopez-Zetina et al. reported a higher syphilis
incidence among drug users less than 45 years old
in Los Angeles, USA11. Taken together the findings
imply that prevention efforts should be targeted to
this young waria population who are at higher risk
for active infections.
A high proportion of waria (96.1%) engaged in anal
sex in the last week with a high frequency (median of
three times/week). Summary analysis of studies from
Europe and USA indicate that, peract, HIV infectivity
of receptive anal sex is about 20 times greater than
vaginal sex12. Waria also tended to initiate sex with
adolescent, a vulnerable group. With this high rate
of high-risk behaviour and syphilis seroreactivity
waria clearly have the potential for HIV acquisition
and transmission13. In addition, a high proportion of
waria (96.2%) also engaged in oral sex with a greater
frequency (median of five times/week) than anal sex.
Per-act risk of HIV infectivity through unprotected
receptive anal and oral sex with HIV positive or
unknown status partners was 0.27% and 0.04%,
respectively14.
Although anal sex poses a great risk of STD/HIV
infection than oral sex, a recent study has shown
that unprotected oral sex between men might be
responsible for as many as 8% of HIV infections15.
In animal experimentation, six out of seven
34
rhesus monkeys became infected with simian
immunodeficiency virus (SIV) after non-traumatic
oral inoculation with cell-free SIV16. In addition,
several strains of SIV can infect both adult and
neonatal rhesus monkeys after oral exposure17.
In Brighton, Bristol, London, and Manchester, the
syphilis epidemic was largely driven by unprotected
oral sex18. In Singapore, female sex workers usually
perceived that they had low vulnerability to HIV and
STD if they engaged in oral sex and were therefore less
likely to ask clients to use condoms19. There had been
an increase in oral sex and pharyngeal gonorrhoea
as a result of a successful condom promotion for
vaginal sex among female sex workers20. The increase
in oral sex and pharyngeal gonorrhoea, concomitant
with a decrease in cervical gonorrhoea suggest that
sex workers engaged in unprotected oral sex, which
was perceived to be safer, when clients refused to use
condom during vaginal sex20. In Bali, Indonesia, none
of the clients of female sex workers used condom
during oral sex21. As in women, in men who have sex
with men oral sex is often unprotected22,23.
In the present study, only 12% of waria consistently
used condoms during any sex act. We did not have
information on condom use during oral sex, but it
is expected to be lower than 12%. In addition, waria
engaged in oral sex more often than anal sex. Thus,
in the prevention campaign, in addition to stressing
the importance of condom use during anal sex, it is
important to warn that STD/HIV transmission can also
occur with oral sex and the risk of oral transmission can
be reduced by condom use. If a condom cannot be used,
ejaculation outside of the mouth may lessen the risk of
STD/HIV transmission24. In addition, factors associated
with an increased risk of oral transmission such as
oral trauma, sores, inflammation, allergy, concomitant
STD, and systemic immune suppression should also
be conveyed in the prevention campaign. Because
waria have the highest documented rates of HIV and
their clients consist of homosexual and bisexual men,
successful prevention efforts in waria could help curb
the spread of the epidemic.
Acknowledgements
The US Naval Medical Research Unit 2 in Jakarta
provided laboratory support for this study. This work
was supported by the US Agency for International
Development Mission in Jakarta, Indonesia.
1
UNAIDS/WHO. Working Group on Global HIV/AIDS and
STI Surveillance. Guidelines for Second Generation HIV
Surveillance, 2000:24± 5
2
Abednego H, Manaf A, Yasan S, Wibisono B, Lazzardi B. Current
situation and trend of HIV/AIDS epidemic in Indonesia. XII
International Conference on AIDS. Geneva, July 1998 [abstract
no. 13150]
3
Taber SR, de Moya EA, Holmes KK, et al. Sexual behaviors and
risk factors for HIV infection among men who have sex with
men in the Dominican Republic. AIDS 1996;10:201–6
4
Surratt HL, Inciardi J, Telles P, McCoy V, Weatherby N. HIV risks
among transvestites and other men having sex with men
in Rio de Janeiro: a comparative analysis. XI International
Conference on AIDS. July 1996 [abstract TU.C.2403]
5
Cabello A, Sequera M, Vera ME, CabralM, Moreno R, Kiefer
R. HIV-risk in male and female sex workers in AsuncioÂ
n, Paraguay: the lack of self protection. XI International
Conference on AIDS. July 1996 [abstract TU.C.2667]
6
Daili SF, Judanarso J, Harjandi B, Indriatmi W, Makes B. Beberapa
penyakit menular seksual pada kelompok waria di Jakarta
(Sexually transmitted diseases in transvestite population in
Jakarta). Proceeding National Congress of the Indonesian
Dermatovenerologist Association, Ujung Pandang, Indonesia,
1998:71– 4
12 Halperin DT. Neglected risk factors for heterosexual HIV
infection: anal intercourse, male circumcision, and dry sex. XIII
International Conference on AIDS. Durban, South Africa, July
2000 [abstract TuPeC3477]
13 Royce A, Sena A, Cates W, Cohen MS. Sexual transmission of
HIV. N Engl J Med 1997;336:1072–8
14 Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K,
Buchbinder SP. Per-contact risk of human immunodeficiency
virus transmission between male sexual partners. Am J
Epidemiol 1999;150:306–11
15 Stephenson J. HIV risk from oral sex higher than many realize.
JAMA 2000;283:1279
16 Baba TW, Trichel AM, An L, et al. Infection and AIDS in adult
macaques after non-traumatic oral exposure to cellfree SIV.
Science 1996;272:1486–9
17 Ruprecht RM, Baba TW, Liska V, et al. Oral SIV, SHIV, and HIV
type 1 infection. AIDS Res Hum Retrovir 1998;14(Suppl): 103
18 UK Public Health Officials warning of HIV risk from oral sex.
Access date July 9, 2001 [hiv.medscape.com/reuters/ prof/20
01/07/07.06/20010705publ002.html]
19 Lian WM, Chan R, Wee S. Sex workers’ perspectives on condom
use for oral sex with clients: a qualitative study. Health Edu
Behav 2000;27:502–16
20 Wong ML, Chan RK, Koh D, Wee S. Increase in oral sex and
pharyngeal gonorrhoea: an unintended effect of a successful
condom promotion programme for vaginal sex. AIDS
1999;13:1981–2
7
Merino HI, Richards JB. An innovative program of venereal
disease case recording, treatment and education for a
population of gay men. Sex Transm Dis 1977;4:50– 2
8
Janda WM, Bohnoff M, Morello JA, Lerner SA. Prevalence
and site pathogen studies of Neisseria meningitidis and N.
gonorrhoeae in homosexual men. JAMA 1980;244:2060± 4
9
Lewis JS, Fakile O, Foss E, et al. Direct DNA probe assay for
Neisseria gonorrhoeae in pharyngeal and rectal specimens. J
Clin Microbiol 1993;31:2783–5
22 Meris RS, Dufour A, Alary M. Patterns of oral sex among men
who have affective and sexual relationships with other men
(MASM) in Montreal. XII International Conference on AIDS.
Geneva, July 1998 [abstract no. 23117]
10 Aral SO, Soskoline V, Joesoef RM, O’Reilly KR. Sex partner
recruitment as risk factor for STD: clustering of risky modes.
Sex Transm Dis 1991;18:10–17
23 Silva S, Portella J, Longo PHP. Unprotected oral sex among men
who have sex with men (MSM). XII International Conference
on AIDS. Geneva, July 1998 [abstract no. 23142]
11 Lopez-Zetina J, Ford W, Weber M, et al. Predictors of syphilis
seroreactivity and prevalence of HIV among street recruited
injection drug users in Los Angeles County, 1994± 6. Sex
Transm Infect 2000;76:462–9
24 Robinson EK, Evans BG. Oral sex and HIV transmission.
[Review]. AIDS 1999;13:737–8
21 Fajans P, Wirawan DN, Ford K. STD knowledge and behaviours
among clients of female sex workers in Bali, Indonesia. AIDS
CARE 1994;6:459–75
35
Epidemiology & STI
References
Prevalence of Sexually Transmitted Infections (STI)
and High Risk Behaviours among Male Street Children
in Jakarta, 2000
Translated from Prevalensi Infeksi Menular Seksual, Faktor Risiko dan Perilaku di Kalangan Anak Jalanan yang Dibina Lembaga
Swadaya Masyarakat di Jakarta, Tahun 2000.
Endang R Sedyaningsih1
Umar Firdous1
Faisal Yatim1
Devy Marjorie1
Maria Holly1
1
Bul. Penelit. Kesehat. 33 (3) 2005: pp.99-110
Abstract
A rough estimate of 4 to 20 thousand children work and/or live in the streets of Jakarta. These children are at the ages where sexual
awareness and activities are rising. Living in an environment where regulations and socio-spiritual norms are more lax gives then more
freedom to be sexually active. Previous study showed that many of them were forced to start sexual lives at early age by older peers, some
were forced to enter prostitution. All of these put the street children at high risk to get sexually transmitted infections (STI), including HIV.
So far, there had not been any STI survey study conducted among this community in Indonesia. The objectives of this study were to measure
the prevalence of gonorrhoea, chlamydia, syphilis, and HIV infection among male street children in Jakarta, and to investigate their risky
behaviours. In the year 2000, male street children aged 10 to 20 years in Jakarta who were reached-out by NGOs were interviewed using a
short questionnaire. Specimens of venous blood, urethral, anal and throat swabs were taken for laboratory tests. As the results, among the
274 children who participated, more than half (58.4%) were children “on “ the street (had somewhat regular contact with their family), and
the rest were children “of’ the street (little or no contact with the family). Knowledge of STI was low, while 22.3% admitted to be sexually
active (one out of 3 children “of’ the street). Condom use was very low: 85.2% among the sexually active never used condoms and only 5%
used it continuously. The prevalence of gonorrhoea was 7.7%, chlamydia 7.4%, syphilis 0% and HIV 0%. Self-treatment was practiced by
31.4% of the participants.
Key words: STI, high-risk behaviours, street-children
Introduction
Not many studies on street children have been
conducted in Indonesia, including Jakarta, which is
roughly estimated to have 4000 to 20000 children
“who live on the streets”.1 Studies from other countries
show that these children were forced to leave their
homes due to many factors inside and outside their
families, such as poverty, family dysfunction, parental
violence, degradation of moral, social, and spiritual
values, inadequate housing, as well as lack of facilities
for children’s activities.1,2 In Jakarta, a study carried out
by PACT (Private Agencies Collaborating Together)
and Catholic University of Atma Jaya showed that
45 street children whom they interviewed stated
the following reasons for leaving their homes: after
severe punishment because they failed to fulfill their
parents’ expectations, family dysfunction, loss of one/
both parent(s), and domestic violence.3
These street children generally were young. Being in
an environment with loose laws and socio-religious
norms that led them to being liberal about sexual
activities. Studies show that many among them
were forced to conduct sexual activities at an early
age by older kids or even forced to enter the world
of prostitution.3,4 All thiese factors make street
children at risk of Sexually Transmitted Infections
(STI), including HIV. However, a study on STI amongst
street children in Indonesia hasn’t been done yet in
order to find the gravity of this problem. Information
from various Non Governmental Organizations
(NGO) who work with street children in Bandung and
Jakarta revealed that quite many street children had
experienced signs and symptoms of STI, and that
they commonly medicated themselves.5
STI have been proved to ease transmission of HIV
through sexual route.6 Because the lifestyle of street
children involves sexual contact, both heterosexually
and homosexually, this group is vulnerable to being
infected with HIV. Since STI control has proved to
decrease incidence of HIV, the HIV/AIDS prevention
program for street children must also include an STI
control component.7
In Jakarta, there are several intervention programs
for street children, such as occupational training,
housing, schools, and so on. Some of these are run by
NGOs and others by the government. For example,
there are seven homes run by the Social Ministry’s
Regional Office collaborating with NGOs. Efforts
on preventing STI/HIV are limitedly, and attempt to
change street children’s behaviors. There are still very
few facilities that provide STI treatments to them. In
39
Epidemiology & STI
Prevalence of Sexually Transmitted Infections (STI)
and High Risk Behaviours among Male Street Children
in Jakarta, 2000
Epidemiology & STI
order to implement STI health care services for street
children, the severity of this problem amongst them
along with their related risky behaviors must first be
known.
The objective of this survey conducted in JuneNovember 2000 was to determine the prevalences
of syphilis, gonorrhea, and Chlamydia, as well as
identifying risky sexual behaviors among street
children in Jakarta.
The study population was street children aged 10
to 20 years of age whom NGOs could reach out to,
were approached at several locations in Jakarta. For
practicality of collecting specimen from genitalia,
only male street children were taken. Participation of
respondents was managed together with NGOs that
were closely connected with this study population.
It was difficult to obtain data from all NGOs with
programs for street children, hence, the number
of street children in touch with NGOs was also
unknown. However, an effort was made to reach
the entire population found at the chosen locations.
Participation was fully dependent on the children’s
consent.
Remembering that STI’s prevalence among street
children has never been known earlier, using an
estimation of STI prevalence being 50%, with
calculation formula of one population sample
(confidence interval 95%, power 5%, and deviation
5%), the number of needed sample was 267. By
taking into account the presence of samples not
fulfilling the requirements, it was planned to obtain
a sample of 300 children. Subsequently, the research
team only managed to examine 274 respondents.
The team was aware that conducting STI examinations
among street children is very difficult, especially when
physical examinations and specimen collections for
laboratory tests was to be performed. This study
attempted to fulfill the ethical rules as much as
possible. Firstly, the lower age limit of 10 years old was
chosen, since at that age a child starts to show plenty
of reasoning. Secondly, the aspect of voluntariness
was very much considered; children were free to
come to and go out of the examination places. They
were also free to communicate with each other, so
that those who had not been examined may hear
stories from those who had undergone examination
40
so that they could decide about their participation
in the study. Thirdly, the children’s needs were paid
attention to; for example, the tools for collecting
specimen were adjusted in sizes. Those who sought
for medical aid for ailments unrelated to STI were also
provided free medications. Fourthly, they were given
money for transportation to replace their otherwise
working time. Fifthly, because the study was carried
out for 2 months at the same places, the research
team was easily available for contact if any complaints
occurred after collection of specimens. In fact, during
the course of this study, almost no complaints were
received.
Before recruitment, information regarding the survey,
lab tests, procedures, benefits, and possible dangers
were conveyed to the prospective respondents.
Children aged 15 or above who were willing to
become respondents were asked to sign informed
consent forms, while those under 15 were asked
for signatures from their guardians, which in this
case were their “Older Brothers/Sisters” from related
NGOs.
Data on behaviors were collected using
questionnaires. Questions comprised of knowledge
about STI, condoms, experiences in sex and illegal
drugs (narcotics, alcohol, psychotropics, and other
addictive substances).
Specimen collection was done by doctors and
paramedics. From each respondent a throat, urethral,
and anal swab was taken with three different cotton
buds. Swabs were inserted into special transport
media GenProbe. Each swab specimen was tested
for Chlamydia and gonorrhea using the GenProbe
test. Venous blood was also taken. The blood was
then tested for syphilis using RPR (Rapid Plasma
Reagin) test and confirmed with TPHA (Treponema
palidum hemagglutinin) test. Lab tests were carried
out at the Centre for Research and Development
of Disease Control, Indonesian Ministry of Health,
Jakarta.
The data was recorded and analyzed with an Epi-Info
6 program. This study obtained consent for research
ethics (ethical clearance) from Ethics Commission
of Health Research and Development, Indonesian
Ministry of Health. Informed consent forms were
provided to be signed by respondents or their
guardians for those under 15 years old.
Results
Until the end of this study, 275 respondents, 825
swab specimens, and 275 serum specimens were
obtained. However, 1 respondent who was 24 years
old was removed and his specimen was not utilized.
The street children were approached by several
NGOs who had activities and programs of guidance/
nurture for street children or rumah singgah:
Yayasan Bintang Pancasila, Yayasan Komunitas Aksi
Kemanusiaan Indonesia (KAKI), Yayasan Gema Mandiri
Bangsa, Yayasan Aji Kinasih Kencana, Yayasan Setia
Kawan II, Yayasan Aisyiah, and Yayasam Kesejahteraan
Anak Indonesia. Respondents came from Jakarta’s 5
districts, especially East Jakarta (Table 1). From the
questionnaires several characteristics of respondents
were obtained (Table 2).
Among the street children who consented for the
survey as respondents, 160 (58,4%) still lived with
their parents. The remaining 114 (41,6%) were not
living with their parents. From the latter, 7 kids (6%)
just recently left their parents (less than 1 year), 33
kids (29%) had moved out 1-2 years, 35 children
(30,7%) at 2-5 years, 23 kids (20,2%) at 5-10 years,
and 4 kids (0,2%) were no longer with their parents
for more than 10 years. Despite this, many of them
often or sometimes went back to their homes and
took their earnings.
One hundred and eight (94,7%) out of the 114 kids
who had left their homes conveyed their reasons
for doing so, which were diverse. Generally, their
reasons were classified as follows: a) 20 kids (18,5%)
endured harsh treatment (beaten/scolded by their
parents); b) 18 kids (16,7%) didn’t feel comfortable at
home (parents fought, incompatible with sibling(s),
desolate environment); c) 30 kids (27,5%) wanted to
be free and independent; d) 14 kids (13,0%) wanted
to help earn money; e) 8 kids (7,4%) were asked for
help by their friends; f ) 18 kids (16,7%) had other
reasons (tailed along with relatives, lack of progress
at their villages, and so on).
Knowledge of these children regarding STI risks can
be seen on Table 3. The most frequently mentioned
STI symptom was “secretion of pus while urinating” by
16 kids (5,8%) and difficulty or pain in urinating by 11
kids (4%). The consequences or complications of STI
most frequently conveyed were “death (due to AIDS)”
by 13 kids (4,7%). Regarding sexual experience, in
fact 61 of them (22,3%) have had sexual intercourse.
The average age of their first sexual encounters was
15 years of age (range 7 to 18 years of age). Most of
them (mode) did it at the age of 15, as many as 15
kids. Other details regarding these sexual experiences
can be seen on Table 4. Table 5 portrays other risky
behaviors of street children. Table 6 shows the results
of analysis of STI history among street children,
behaviors in seeking treatment, and diagnosing STI
syndromes. From those who admitted to “treating
themselves”, in fact 44% of them bought their
own medicines, while the remaining either drunk
traditional herbal beverages, rested, had massages,
or plainly ignored the symptoms.
During physical examination several complaints,
signs, and symptoms were found, thus enabling
the establishment of diagnosis using the syndromic
approach. Lab results for STI are presented in Table
7. Bivariat analysis using cross tabulations for several
variables was carried out. The results can be viewed
on Tables 8, 9, and 10.
Discussion
Although the count is still limited, studies or literature
reviews that cover risky behavior of Indonesian street
children have been conducted and almost all of
them report high-risk behaviors for STI transmission,
including HIV infection.1,3,4,9 For example, a study
done by Catholic University of Atma Jaya in 1995
discovered that 44% of street children (mainly boys
aged 11-17) had experienced sexual harassment.3
Fifteen out of 53 (28,3%) male street children under
18 years of age in Jakarta who were surveyed by
KOMPAS’s Research & Development team in 1997
had sexual intercourse (half of them had engaged
in homosexual activity).10 This also occurred in
Semarang, 31% of 101 street children (boys and
girls) studied by Yayasan Duta Awam, Paguyuban
Anak Jalanan Semarang, and Semarang’s Regional
Government in 1997 gave history of sexual activity;
41
Epidemiology & STI
Following examinations, respondents diagnosed
with STI based on the syndrome approach were given
free treatment according to the Ministry of Health’s
regulations.8 Respondents who complained of other
illnesses were also given free treatments. If lab tests
showed positive STI results and the respondent
had not yet been given treatment, subsequent
free treatment was given through the related NGO.
Besides that, respondents also received cash to cover
for transports.
Epidemiology & STI
Table 1. Area and Location of Gathering among Street Boys
Who Are Assisted by NGOs, Jakarta, 2000, N = 274
Area
Number of
Children
Location
North Jakarta
West Jakarta
Cilincing, Kelapa Gading, Jembatan
Merah, Pedongkelan, Tanjung Priok
Tomang, Slipi, Kalideres,
Kemanggisan, Kawi
Central
Jakarta
Salemba, Menteng, Cempaka Putih,
Senen, Kali Pasir, Galur, Jl. Murda'I,
Jl. Mardani, Pramuka, Rawasari,
Cikini, Pasar Rumput
East Jakarta
Pulogadung, By pass, Kalimalang,
Cakung, Jatinegara, Jl. Pemuda, Kayu
Manis, Kampung Melayu, Kampung
Makassar, Matraman, Rawamangun,
Pedongkelan, Pura Bali, Pangkalan
Jati, Pondok Bambu, Kramat Jati,
Cililitan, Prumpung, Utan Kayu
South Jakarta
Manggarai, Pancoran, Blok M,
Komdak Sudirman, Ragunan
11 children
20 children
29 children
186 children
28 children
Table 2. Characteristics of Street Boys Who Are Assisted by NGOs,
Jakarta, 2000
Characteristics
Age mean
age range
Education Period
never gone to school
1-6 years
>6-9 years
>9-12 years
>12 years
Origin of Father
Java:
Jakarta
West Java
Central Java, Yogyakarta
East Java
Sumatera:
Aceh, North Sumatera
Riau, Jambi
West Sumatera
South Sumatera, Lampung
Others:
South Kalimantan
Unknown origin
42
N=274
15 years (modus: 16)
10-21 years (25%ile: 13;
75%ile: 16)
%
5
131%
110.0%
25
2
1.8
47.8
40.1%
9.1
0.7
229
74
86
47
22
36
83.6
27
31.4
17.2
8.3
13.1
1
6
0.4
2.3
Table 3. Knowledge about the Risk of Getting STI among the Street Boys,
Jakarta, 2000, N=274
%
Epidemiology & STI
Knowledge
Have ever heard about AIDS
yes
no
Declaring 2 types of STI cases correctly
75.5
24.5
yes
17.5
no
82.5
Declaring 2 types of STI symptoms correctly
yes
no
Declaring 2 types of complications of STI
correctly
yes
no
10.5
89.5
3.3
96.7
Table 4. Sexual Experience of the Street Boys, Jakarta, 2000, N = 61
Sexual Experience
%
First time having sex with
female
male
Reason for doing the first sex
love
coercion
buying sex
selling sex
not answered
Relationship with the partner of first sex
girlfriend/boyfriend
friend
female sex worker
transvestites
others
Frequency in doing sex after the first sex
experience
>1 time/day
1-7 times/week
1-3 times/month
<1 time/month
not answered
88.5
11.5
73.8
9.8
8.2
6.6
1.6
50.8
26.2
13.1
6.5
3.2
Sexual Experience
Reason for doing sex after the
first sex experience
love (does not need to pay)
paying to get sex
paid for sex
sometimes paying to get sex
not answered
Sex mode
vagina
anal sex (insertive)
anal sex (receptive)
oral sex (receptive)
oral sex ((insertive)
Condom Use
always
seldom
never
13.1
32.8
0
49.2
5
not answered
%
57.4
18
11.5
1.6
11.5
77
5
6.6
3.3
6.6
4.9
6.5
85.2
3.2
43
Epidemiology & STI
Table 5. Other risky behavior found at male anak jalanan those are under
assistance of NGO, interviewed, Jakarta, 2000. N = 274
Risky Behavior
Consuming Alkohol
yes
23.0%
never
50.4%
Smoking
yes
61.0%
never
21.8%
Consuming Drugs
yes
18.2%
never
67.6%
Using Injecting Drugs
yes
2.2%
never
94.2%
IF yes/ ever,did you share the srynge? (n=12)
yes
never
Sniffing in Adhesive substance
yes
8.8%
never
78.5%
ever (not anymore)
no response
26.4%
0.4%
ever (not anymore)
no response
13.5%
0.7%
ever (not anymore)
no response
13.5%
0.7%
ever (not anymore)
no response
2.2%
1.4%
50.0%
50.0%
ever (not anymore)
no response
11.3%
1.4%
Diagnosis of
Table 6. STI history, Treatment Seeking Behaviour, and Syndromic
Diagnosis Syndrom
Streets boys under assistance of NGO, Interviewed, Jakarta, 2000 (N=274)
Complaints/ symptom
pain during urination
pus during urination
wound at genital area
genital warts
inguinal swelling
Mode/ Health Facility
Health Center/ Hospital
Doctor's Private Practise
Nurse/ Orderly's Private practice
Traditional healer
Self Treatment
No response
Syndromic Diagnosis
urethral discharge
genital warts
Lymphadenopathy
no abnormality was found
44
45.6%
6.6%
12.4%
5.5%
25.5%
47.1%
3.0%
1.8%
0.0%
31.4%
11.3%
1.1%
0.4%
5.5%
93.1%
of streets boy under assistance of NGO
Table 7. STI prevalence on
interviewed based on the type of specimen, Jakarta, 2000, N=274
Speciment
p
Gonorrhoe
n=274
%
2
0.7
3
1.1
17
6.2
anal swab
throat swab
urethral swab
anal/throat/urethral
swab
vein blood
21
7.7
Sexually Transmitted Infection
Clamidia
Gon/Clam
n=274
%
n=274
%
4
1.4
6
2.2
5
1.8
6
2.2
12
4.4
26
9.5
20
7.4
36
HIV/Syphilis
%
13.9
0
0
Table 8. Distribution of sexual behavior based on type
of streets boy under assistance of NGO on interview, Jakarta,
2000, N = 274
Sex
Intercourse
ever
never
Quantity
Children on
the street
17
143
160
Children
of the
street
44
70
114
Quantity
61
213
274
Table 9. STI Distribution based on sex intercourse
in the respondent who had sex intercourse,
behavior found at
Jakarta, 2000
Suffering
from one
of any STI
14
22
36
Sex Intercourse
ever
never
Quantity
No suffering
from any of
STI
47
191
238
Quantity
61
213
274
R=2.2; p value:0.02
Table 10. STI distribution based on the mode of sex
intercourse at streets boys under assistance of
NGO, interviewed, Jakarta, 2000, N=274
Sex
Intercourse
anal sex
ever
never
oral sex
ever
never
intercourse
ever
never
(RR=2.9;p:0.01)
No
suffering
Suffering from from any
one of any STI
of STI
STI around Anal area
0
7
6
261
STI around throat area
0
5
6
263
STI around uretra
10
37
16
211
Quantity
7
267
5
269
47
227
45
Epidemiology & STI
yp
Epidemiology & STI
despite the fact that their average age was 16.11
Although behavior stated above is highly risky for
transmission of STI, there is almost no data showing
the severity of STI among Indonesian street children.
For this reason, this survey was conducted, with the
intention of answering many questions regarding
the prevalence of STI among street children, more
precisely among male street children in Jakarta.
The sample number in this study was small if compared
to the population of street children in the entire region
of Jakarta, which is estimated to be 4,000-20,000.1
Besides that, the selected street children sample was
also limited to those who have received guidance from
NGO activists. This was intentionally done to facilitate
the approach to respondents. In other words, this study
population maybe at relatively less risk compared
to the entire street children population. However,
since there is almost no data on the prevalence of STI
among street children, this study’s results can portray
the occurrence of STI; but the obtained results may
show bias towards the lower side.
This study is also only limited to male street children.
Besides the fact that male street children comprise
the biggest portion of street children, the procedures
of examination and specimen collection from girls
are much difficult from the technical and ethical
points of view. This is primarily due to specimen
collection that requires use of speculum. An alternate
design will be to conduct a non-invasive study on
STI prevalence among girls, which will use urine
specimens tested with PCR method but will require
a large sum of funds.
From the characteristic of age, it can be seen that
although the age range taken was quite big, being
10-21 years old, most of them (78,2%) are between
12-17 years old, with an average age of 15 years and
median age of 16 years.
Data on education showed that although the
obligatory education program has long been
implemented, 5 kids (1,8%) admitted to have
never been to school. The fact that most (83,6%)
respondents originated from Java was unsurprising,
remending how easy the transportation to Jakarta
was. The further away from Jakarta, the lower the
sample proportion should be. Despite this, the
number of street children who migrated from
Sumatra was quite high (13,1%).
46
According to Aneci Rosa et al (1992) and Gross et
al (1996), as quoted from Julianto’s paper, street
children were divided into two categories: “children
on the streets”, who still made regular contacts with
their families, and “children of the street”, who rarely
or never contacted their families.9
In this study, 160 (58,4%) children still lived with
their parents, hence were in the first category. The
remaining 114 (41,6%) no longer lived with their
families, though many of them still sometimes visited
their parents while taking their earnings. They were
categorized in the second group. More than a third of
the children on the street (35,2%) ran away from their
families due to the lack of harmonious relationships
or had endured harsh treatment at home. This
number was relatively smaller compared to Irwanto
et al’s study which showed that most of the 45
interviewed children ran away from home because
they were punished by their parents/witnessed too
much domestic violence/had parents who were in
constant conflict or had died.3
Knowledge-wise, the word AIDS seems to have
already been well known to them (75,5% had heard
of it). But knowledge of STI was minimal.
Other studies showed that children “of” the street had
higher risks of being sexually harassed than children
“on” the street (one of two children, compared to
one of ten, respectively).10 In reality, this study also
showed a similar result that 61 (22,3%) children
admitted to having sexual intercourse. Among
the children of the street, one out “of” three had
experienced it, whereas among the children “on” the
street only one out of nine had (Table 8).
Interestingly, 45/61 (73,8%) children who admitted
to having had sex engaged in their first sexual
encounter out of mutual liking; hence it was not
forced. Seventy-seven percent did sex with a
girlfriend or a friend. The average age of these first
sexual experiences was 15 years of , with a median of
15 years. These facts supported the assumption that
street children (both those “on the street” and “of the
street”) lived in a more permissive environment to be
more free in engaging in sexual activities. It was also
proved that about 46% of them admitted to being
sexually active, having sex at least once a week, some
even doing it several times a day.
Although in general the prevalence of STI among
street children can be said as moderate (gonorrhea
and/or Chlamydia 13,1%), the prevalence of STI
among street children who admitted to having
had sex was 23%. This value might even still be low
estimation, considering the presence of respondentbiases.
From interviews, 7 children admitted to frequently
having anal sex (both receptively and inserting).
When analysed with STI data, STI signs on anus were
not found. On the other hand, there were 6 others
who didn’t admit to ever having anal sex but showed
STI signs on their anus. Similarly, 5 kids who admitted
to having had oral sex none showed STI signs in
their throats; whilst among 6 others who admitted
to not have had oral sex, their throats showed signs
of STI. Furthermore, among 225 children who stated
to have never had sex per vagina, in fact 16 (7,1%)
had urethral infections. These results confirmed the
presence of respondent bias relating to data of sexual
behavior. Even so, vaginal sex still had a significant
correlation with urethral infection (RR = 2,9; p value:
0,01) (Table 10).
Although sexual behaviors of street children are
highly risky, condom usage was minimal; only 4,9%
always and 6,5% rarely used them. This was despite
the fact that 67,2% of them knew about and had seen
condoms. From the conversations, in reality many of
them had listened to mass or public socializations
or counseling about HIV/AIDS from NGOs. However,
those events might only have increased awareness
and knowledge, but not achieved behavior change.
Other risky behaviors were also encountered, such as
drinking alcohol, smoking, taking illegal drugs, doing
injections of narcotics, and sniffing glue (see Table
5). Seeing respondent bias regarding information
of sexual behaviors, there’s a high possibility that
Bul. Penelit. Kesehat. 28 (3&4) 2000
information about other risky behaviors, a bias
towards lower value might also exists. This especially
applies for children who admitted to having engaged
in risky behaviors but no longer did them now
(around 25 until 100% of these children said “yes”).
As a whole, the children’s behaviors of seeking
medication was still classified as being good, where
52% sought professional help. Analysis of the STIpositive data also revealed no significant differences
in behavior of seeking medication between the
STI-positive and the STI-negative children. During
conversation, it was found that many of those
children received some kind of a medication card
from NGO, enabling them to visit the nearby primary
heath care center.
Bearing these street children’s high-risk sexual
behaviors in mind, a health service program for them
needs to be established, both for general health and
for STI. Other than that, the related NGO need to
be supported to provide interventions for behavior
change and harm reduction.
Special Thanks
The research team would like to thank the street
children for their participation in this study.
Gratitude also goes to our colleagues from the
various Non Governmental Organizations, especially
from Yayasan KAKI (Komunitas Aksi Kemanusiaan
Indonesia), who have helped the course of this study.
To Dr. John Moran, the STD Advisor of HAPP (HIV/
AIDS Prevention Project), we offer thanks for your
corrective suggestions of this paper. We also thank
HAPP and PATH (Program for Appropriate Technology
in Health) for the provision of tools and materials
of laboratory tests. This study was funded by the
Indonesian Government through the Directorate
General of PPM-PL.
Reference
I.
Black B., Farrington A. P.. Preventing HIV/ AIDS by promoting
life for Indonesian street children. AIDS Caption, 1997; 4(1):1417.
2.
Childhope, Executive Summary. First regional conference/
Seminar on street shildren in Asia: Mobilizing community
actions for street children. Manila1989; May 4-13, 1989.
3
Irwanto, Moelinno L., Lien n.A, .1 review c` the lifestyles of
street children in Jakarta: Toward program development to
prevent STD and HIV/AIDS infection. Unpublished manuscript.
Jakarta, 1995; Atmajaya Research Centre.
4.
Mboi N. Children and youth on the streets: At risk from AIDS
but what can we do? Reflections on the Indonesian situation.
Presented in the South-East Asian Regional Consultation,
Manila 1992; November 15-21, 1992.
47
Epidemiology & STI
After analysis of the STI test results, it was found
that the respondent bias regarding data of “having
experienced sexual contact” was low. Of the 22
kids who stated that they never had sex, signs of
gonococcal and/or chlamydial infections were
found on one of their organs (anus and/or throat
and/or urethra). Also, analysis showed a significant
correlation between “having experienced sex” with
being infected by an STI (RR = 2,2; p value: 0,02)
(Table 9).
Epidemiology & STI
5.
Utomo H. Yayasan Bina Sejahtcra Indonesia, Bandung:
Pandoyo. Yayasan Griya Asih, Jakarta. Personal communication,
November 10, 1997.
6.
Wasserheit J.N. Epidemiological synergy: Interrelationship
between HIV infection and other STDs. Sexually Transmitted
Disease, 1992; 19:61-77.
7.
S.
Grosskurth H., Mosha F., Todd J., Mwijarubi E., Klokke A.,
Senkoro K., Mayaud P.. Changalucha J., Nicoll A., Gina G., Newell
J., Mugeye K., Mabey D., Hayes R. (1995). Impact of improved
treatment of sexually transmitted diseases on HIV infection
in rural Tanzania: Randomized controlled trial. Lancet, 346:
530536.
Departemcn Kesehatan RI, Direktorat Jenderal PPM-PLP.
Penatalaksanaan penderita penyakit tnenular seksual (PMS)
dengan pendekatan sindrom: t3uku Pedoman Interaktif.
Jakarta, 1997.
48
9.
Julianto 1. Anak jalanan dan HIV/AIDS: Analisis hak asasi
manusia dan faktor kon-tekstual. Makalah disampaikan dalam
Seminar AIDS dan Kelangsungan Hidup Anak. Jakarta, 19
September 1997 .
10, Setiax%an, B. Yang lemah dan menjadi korban. Tinggalkan
keluarga, Hidup dalam bahaya, Menyingkap kehidupan bajing
loncat anak-anak. KOMPAS. 13 Juli 1997.
11. Anak jalanan di Semarang: 31 persen pemah lakukan
hubungan seksual. REPUBLIKA, 3 Mei 1997.
Nia Kurniati1
T Nilamsari1
Arwin AP Akib1
1
Department of Child Health, Medical School, University of Indonesia, Jakarta,
Indonesia.
Paediatr Indones. 2006 Sep-Oct;46(9-10):209-13.
Indonesian Society of Pediatricians
49
Epidemiology & STI
Incidence of HIV-Infected Infants Born to
HIV-Infected Mothers with Prophylactic Therapy:
Preliminary Report of Hospital Birth Cohort Study
Abstract
Background: Human immunodeficiency virus (HIV) is expanding rapidly and was reported double in several places in Indonesia. To our knowledge,
reports regarding HIV-infected infants are still scarce. Objectives: To investigate the incidence of HIV-infected infants born to HIV- mothers who
had received prophylaxis therapy at birth. Methods: A prospective hospital-based cohort study was held from January 2003 until December 2004
in Cipto Mangunkusumo Hospital, Jakarta. The inclusion criteria were mothers with positive HIV and their infants had been given anti retroviral
(ARV) therapy. The babies were followed up monthly and the status of infection was determined by PCR at the age of 4 weeks and 6 months.
Outcome was measured based on PCR assays or clinical signs of HIV infection. Results The mothers’ age ranged from 19 to 27 years. All of them
were carrying their first child and only 41% mothers took ARV prophylaxis. Almost all mothers underwent caesarean section and the infants had
formula feeding. HIV infection was diagnosed in 7 infants and 2 of them had RNA assays more than 5,000 copies/ml. Six infants were negatives
whereas 3 infants were diagnosed as indeterminate HIV infection and needed further examination. One needed no further investigation as
the mother was seronegative. Conclusions: Preventing HIV transmission from mother to infant can be done by giving ARV during prenatal,
intrapartum, and postnatal period to the newborn. In our hospital, transmission was confirmed in 6 of 17 infants. Unison protocol must be used
and population of HIV-pregnant mother must be registered in order to know how high the transmission rate among Indonesian HIV people
[Paediatr Indones 2006;46:209-213].
Keywords: HIV, HIV-pediatric, mother-to-chil dtransmission
Indonesia is now experiencing rapid expansion of
human immunodeficiency virus (HIV) epidemics.
Several places reported double increase of incidence
in the last 5 years. In cities where injecting drug users
were a problem, HIV infections also accounted for a
rise of mortality.1 Adolescents and early adults were
mostly drug-abusers, and they were at the age of
sexually active life. The risk to transmit HIV to a spouse
leads also to the transmission of HIV risk pregnancy,
and ultimately to HIV exposed infant.
Developed countries reported that by conducting
prevention program of mother to child transmission,
the rate of transmission is currently below 2%.2,3 Efforts
consist of recommendation for universal prenatal HIV
counseling and testing, widespread use of highly active
antiretroviral (ARV) therapy and elective cesarean
delivery on HIV-infected pregnant women.
Department of Health of Indonesia assumes that there
are 2,000-3,000 pregnant women with HIV in Indonesia
in 2004.4 Those HIV-mothers given ARV therapy
later during delivery were not yet reported. National
prevention program of mother to child transmission is
intended to be implemented in the recent year.
Our immunology clinic treats infants born to mothers
with HIV since 1996.5 The rate of HIV-transmitted
infants prone to ARV prophylaxis at birth have not
been evaluated. The objective of this study was to
investigate the incidence of HIV-infected infants born
to mother with HIV who had received prophylaxis
therapy at birth. This was only a preliminary report of
a much longer hospital birth cohort project.
Methods
This was a prospective hospital-based cohort study
with short-term follow-up. The study participants were
HIV-1 exposed infants who attended our HIV clinic,
Department of Child Health, Cipto Mangunkusumo
Hospital, Jakarta, from January 2003 to December
2004. They were born in our maternity department
or other hospitals and aged less than 2 weeks. The
inclusion criteria were mother with positive HIV
whether they had or had no ARV before pregnancy,
delivery, during delivery, or post-delivery periods.
The study infants had to have zidovudine with or
without nevirapine since the age of 12 hours.
Data of parents and infants were recorded. Maternal
data included maternal age, risk factors, CD4+ count,
viral RNA levels before delivery, mode of delivery
and information whether she nursed her baby or
not. Paternal risk factors were also recorded. Data of
infants included viral RNA detection, CD4+ count,
and clinical condition. The exclusion criteria were no
ARV given to HIV exposed infants for prophylaxis or
unknown HIV status of the mothers.
51
Epidemiology & STI
Incidence of HIV-Infected Infants Born to
HIV-Infected Mothers with Prophylactic Therapy:
Preliminary Report of Hospital Birth Cohort Study
Epidemiology & STI
Every baby was then followed-up monthly as it was
done to healthy infants and was given immunization
according to protocol set up for exposed infants.
After the age of 6 months, infection status was
determined based on polymerase chain reaction
(PCR) on ribonucleic acid (RNA), serology after 12
months or any sign of HIV infection. Diagnosis of
HIV infection was established using viral diagnostic
assays at the age of 4 weeks and older than 6 months.
Clinical diagnosis of HIV was established according
to 1994 Center of Disease Control criteria. Immunosuppression status was also examined if there were
clinical or laboratory signs of infection.
The end point of the study was confirmation of
HIV–infection status in infants with positive PCR
assays on separate blood specimen. Infection could
also be established if there were clinical signs of HIV
infection. Uninfected infants could be determined
with 2-negative virology assay on separate blood
samples. If the parents could not afford PCR test, HIV
immunoglobulin G (IgG) antibody test performed at
the age of more than 6 months with an interval of at
least 1 month between the tests could also be used
to exclude HIV infection. If there was only 1 sample
tested, both in virology assay and in serologic test,
clinical sign of HIV would confirm HIV infection;
otherwise infection status would be indeterminate
until the end of study.
Results
From January 2003 until December 2004, 17
neonates born to HIV-infected mothers attended
our HIV clinic. Their mothers’ age ranged from 19 to
27 years. Almost all mothers were carrying their first
TABLE 1. CHARACTERISTICS
OF PARENTS
Risk factors
Paternal IVDU-maternal IVDU
Paternal IVDU only
Paternal MPS-maternal MPS
Maternal MPS only
No data
Maternal viral level
Determined
Not determined
Maternal CD4+ count
Determined
Not determined
ARV during pregnancy
>1 month
1 month
<1 month
Not received
Mode of delivery
Elective sectio caesarian
Spontaneous labor
2
9
2
0
4
2
15
9
8
1
1
5
10
16
1
Abbreviation: IVDU=intravenous drug user; MPS=multiple partner sex;
ARV=anti-retroviral.
52
child. During pregnancy only 7 mothers took ARV
prophylaxis, ranged from 1 week before delivery
to the entire pregnancy period. HIV status of the
mother was confirmed by serology antibody test
using enzymelinked immunosorbent assay (ELISA).
Immunosuppression status was determined only in 9
mothers, with all CD4+ >200 cells/ml. Only 2 mothers
had virology assay data, one was 234 copies RNA/ml
and the other one was 26,551 copies RNA/ml.
The risk factors of HIV infections were not all
described in their medical records since there was
great possibility that these mothers got the infection
from their husbands as it is shown in Table 1. Paternal
risks recorded were mostly intravenous (IV) drug
users. Only 2 parents probably had infection through
multiple sex partners.
Almost all mothers (16/17) underwent cesarean
section, and all infants were given formula feeding
to avoid transmission via breast feeding. All but 1
infants were born full-term and their birth weight
ranged from 2370-3900 grams. All of these infants
were still on our monitoring to be followed later.
HIV infection was diagnosed in 7 patients, 2 of them
were categorized as confirmatory infection because
viral RNA level reached >5,000 copies/ml. Both
received ARV therapy. Three patients had RNA assays
<400 copies/ml and no clinical sign of HIV infection
was noted nevertheless 2 of these 3 were given ARV
therapy. The reason why 1 out of these 3 patients was
not given ARV was adherence consideration. One
patient did not have virology assay result because
of financial reason, he developed clinical sign that
fulfilled CDC criteria 1987; and we entered him into
ARV therapy. One last case had 1 negative virology
assay, but he developed BCG-itis so that we gave him
ARV therapy (Table 2).
The descriptions of the rest of 10 infants are as
follow. Two-negative PCR RNA examined on 4 weeks
and >6 months of age were revealed in 6 infants.
Those infants were considered as HIV uninfected.
One negative assay was found among 3 infants, 2 of
them were reported to be unable to undergo second
PCR assay due to financial problem. The others were
not reaching 6 months of age at the end of the
study. In these 4 infants, HIV-infections were still
indeterminate, although 1 infant developed BCG-itis
that we suspected immunocompromised condition.
Further data will be needed to confirm their status.
OF POSITIVE CASES
Case
Maternal
viral level
(copies/ml)
CD4+ count
(cell/ml)
Mode of
delivery
Infant viral level
age 4 weeks
(copies/ml)
Clinical
condition
ARV therapy
Results
1
2
3
4
5
6
7
NA
NA
NA
NA
NA
NA
26.551
925
>200
316
NA
NA
NA
324
SC
SC
SC
SC
SC
SC
SC
<400
8,839
<400
246,509
372
NA
Not detected
Healthy
Healthy
Healthy
Healthy
Healthy
Impetigo FTT
BCG-itis
No
ZDV 3Tc NVP
ZDV 3Tc NVP
ZDV 3Tc
ZDV 3Tc
ZDV 3Tc NVP
ZDV 3Tc
Indeterminate
HIV-infected
Indeterminate
HIV-infected
Indeterminate
HIV-infected
Indeterminate
Abbreviation: ARV=anti-retroviral; NA=not available; ZDV=zidovudine; 3Tc=lamivudine; NVP=nevirapine; FTT=failure to thrive; BCG=Bacillus-Calmette
Guerein
One infant was considered as uninfected even
though she did not undergo virology examination.
Her mother serology test showed negative result
on postnatal repeated examination, although her
husband was proven to be positive HIV.
Retrieving paternal risk factors is usually difficult. They
are usually reluctant to disclose their status. From all
data that we could gather, recent or previous IV drug
user was the important source of HIV infection in this
family. Study from Jakarta revealed that as high as
75% of drug user infected with HIV. 9
Discussion
This study was intended to be a model for a longer
cohort study. It was not an ideal model to describe
HIV transmission rate among Jakarta’s infants
population born to HIV-infected mother since we
were not exposed to all HIV mothers. In this short
cohort, we were anxious to know the impact of giving
ARV prophylaxis to these infants.
According to prevention program of mother to child
transmission (PMTCT), perinatal HIV transmission
was accounted for virtually all cases in our study.
Transmissions in this vertical mode occurred before
delivery (prepartum), during delivery (intrapartum),
and after delivery through breastfeeding. Published
transmission rate worldwide varied from 2% in
developed countries to 40% in Africa. Population
based cohort study showed that with implementation
of PMTCT transmission rate can be suppressed to
4-15%.6
Our patients were infants born to HIV-positive
mothers who were managed to escape HIV infection
by prevention at least with treatment for the baby.
Unison protocol of the mother varied over time
during the study, because the infant received only
zidovudine in the year 2003 and received nevirapine
as additional treatment in the year 2004. Zidovudine
was given for 6 weeks, with doses of 2 mg/kgBW
every 6 hours. This protocol proved to be effective
in study of PACTG 76.7 Nevirapine 2 mg/kgBW as a
single dose was added for infant born to ARV-naïve
mother, according to study of CDC-Thailand.8
Maternal viral RNA levels, lower CD4+counts,
advance maternal disease, prolonged duration
of ruptured membranes, chorioamnionitis, and
associated diseases were reported to increase risk of
HIV transmission.10 Only 2 mothers had data of viral
levels and only 8 mothers had data of CD4+ counts
during pregnancy. One mother had viral RNA level
>10,000 copies/ml and CD4+ count >200 cell/ml.
It turned out that her infant was negative on first
PCR determination. BCG-itis developed at the age
of 4 months and persisted for 3 months in spite of
well-baby condition. He was treated as HIV-infection
even though infection status was indeterminate. He
was given ARV therapy. When facing such situation,
single negative viral test in symptomatic HIV-infected
children should lead to suspicion of HIV infection.
Although symptoms of HIV infection overlapped
with those of other common childhood diseases,
repeated virology test is recommended in this patient
to confirm diagnosis. 2,3,5
Study of pediatric AIDS clinical trials group (PACTG)
protocol 076 showed that by giving zidovudine
at prenatal and intrapartum period to the mother
along with zidovudine 4 times a day for 6 weeks to
the newborn, transmission rate can be suppressed
to 7.6%.7 Furthermore, collaborative study of CDC
and Thailand using prenatal zidovudine, intrapartum
zidovudine plus nevirapine, and zidovudine plus
nevirapine for the newborn showed that transmission
rate was as low as 4.6%.8 Both studies were done on
population of HIV-infected mother. In this study
53
Epidemiology & STI
TABLE 2. DESCRIPTION
Epidemiology & STI
we could not attribute to a certain PMTCT protocol.
Difficulties in early detection of HIV-pregnant
mothers led us to late confirmation of HIV infection
in near-labor mother so that we had no chance to
give ARV before delivery. The data showed that we
had only 6 of 17 infants which later turned out to be
HIV-positive infection and 1 case of indeterminate
HIV infection by giving at least ARV to the newborn.
In 1 case whose mother was considered as negative,
rechecking of data and laboratory reagent usage
should be performed. In this state, retesting in
separate times would alleviate window period or
different sensitivity of different reagent tested.
In conclusion, preventing HIV transmission from
mother to infant can be done by giving ARV during
prenatal, intrapartum, and postnatal period to
the newborn. In our hospital, transmission was
confirmed in 6 of 17 infants. Unison protocol must
be used and population of HIV-pregnant mother
must be registered in order to know how high the
transmission rate among Indonesian HIV people.
References
1.
World Health Organization-regional office for South- East Asia.
HIV/AIDS facts and figures. Cited 2004 September 9. Available
from http: url: //www.who/ searo/HIV-AIDS/factsandfigure.
htm.
2.
The Working Group on Antiretroviral and Medical Management
of HIV-Infected Children, The National Resources and
54
Services Administration, and The National Institute of Health.
Guidelines for the use of antiretroviral agents in pediatric HIV
infection. Cited 2004 November 30. Available from: url: http://
www.aidsinfo.org.
3.
Dorenbaum A, Cunningham CK, Gelber RD, Culnane M,
Mofenson LM, Britto P, et al. Two-dose intrapartum/ newborn
nevirapine and standard antiretroviral therapy to reduce
perinatal HIV transmission. JAMA 2002;288:189-98.
4.
Ditjen PPM&PL Departemen Kesehatan Republik Indonesia.
Laporan triwulan pengidap infeksi HIV dan kasus AIDS sampai
dengan Desember 2004.
5.
Akib AAP. Infeksi HIV pada bayi dan anak. Pertemuan Ilmiah
Tahunan Ikatan Dokter Anak Indonesia. Batam. June 2004.
6.
Mofenson LM. Overview of perinatal intervention trials.
Cited 2005 March. Available from: url: http:// www.
womenchildrenhiv.org/
7.
McSherry GD, Shapiro DE, Coombs RW. The effect of
zidovudine in the subset of infants infacted with human
immunodeficiendy virus type-1 (Pediatric AIDS clinical trials
group protocol 076). J Pediatr 1999;134: 717-24.
8.
Chalermchokcharoenkit A, Asavapiriyanont S, Teeraratkul A,
Vanprapa N, Chotpitayasunondh T, Chaowanachan T, et al.
Combination short-course zidovudine plus 2-dose nevirapine
for prevention of mother-to-child transmission: Safety,
tolerance, transmission, and resistance results. 11th Retrovrus
and Opportunistic Infection Conference. San Fransisco,
February 2004.
9.
Djauzi S, Djoerban Z. Penatalaksanaan infeksi HIV di pelayanan
kesehatan dasar. Edisi ke-2. Jakarta: Balai Penerbit FKUI; 2003. p. 67.
10. Ammann AJ. Pediatric human immunodeficiency virus
infection. In: Stiehm ER, Ochs HD, Winkelstein JA, editors.
Immunologic disorders in infants and children. 5th edition.
Philadelphia: Elsevier Saunders; 2004. p. 878-951.
Professor John Kaldor1
Dr. Matthew Law1
Julienne McKay1
Karina Razali1
Dr. Heather Worth2
Klara Henderson3
Bob Warner4
1
National Center in HIV Epidemiology & Clinical Research, University of New
South Wales.
2
National Center in HIV Social Research, University of New South Wales
3
Independent Consultant.
4
The Center for International Economics.
Australian Government
AusAID 2006
www.ausaid.gov.au
55
Epidemiology & STI
Impact of HIV/AIDS 2005-2025 in Papua New Guinea,
Indonesia and East Timor
Introduction
The HIV Epidemiological Modelling and Impact
(HEMI) Study was funded by the Australian
Government through AusAID, to be undertaken in
relation to the sub-region incorporating Papua New
Guinea, Indonesia and East Timor.
In May 2005. New South Global Pty Limited, the
consulting company of the University of New South
Wales, was commissioned by AusAID to conduct
the study. The complete study will be published as
a separate volume and available from the AusAlD
website www.ausaid.gov.au.
The study was undertaken in four parts. First, the
research team worked with AusAID to identify incountry partners and data sources. In the second part
of the study, mathematical models were developed
to predict the course of the HIV epidemic based on
the best available epidemiological data and three
different intervention scenarios. Next, the output
of the epidemic model was applied to forecast the
economic and social consequences of HIV/AIDS
under each of the three intervention scenarios
and to provide cost effectiveness analyses of the
interventions. Finally, in-country workshops were
held to present and discuss the results.
Epidemiological Model for HIV
Transmission
For the purposes of the HEMI study, an HIV
transmission model was developed that could
be adapted for use in each country under various
scenarios. The model was calibrated against the most
recent national HIV prevalence estimates, where they
were available. Within the adult populations of each
country, subpopulations considered in the model
were female sex workers, male clients of female sex
workers, men who have sex with men, injecting drug
users (male and female) and other adults. The generic
transmission model also distinguished between
urban and rural regions, age groups and categories
of HIV-disease progression (early stage HIV infection,
later stage HIV infection and AIDS). In order to apply
the model for a given country information is needed
about the sizes of all defined subpopulations. the
frequency of contacts (sexual and drug injecting)
between members of the subpopulations, and the
rate of HIV transmission that occurs when different
types of contact take place.
A model of this kind is understood to be a vast
oversimplification of the real dynamics of HIV
transmission in a human population.
Furthermore, it’s dependent on assumptions about
sizes of subpopulations and transmission rates that
are based on limited sources of data. Although it is
generally not possible to validate the models in an
absolute sense, it is important to ensure that they
are based on the best available data, that they are
conceptually coherent, and that they predict levels
of HIV prevalence that are broadly consistent with
observed levels.
The model was separately adapted for Papua New
Guinea, Indonesia and Fast Tunor based on the
best available epidemiological and behavioural
data for each country. For Papua New Guinea the
model was calibrated against the 2004 national
prevalence estimates and for Indonesia the most
recently published national prevalence estimates
of 2002. Assumptions were made to define the
epidemiological characteristics of HIV transmission
in each of the three countries. These assumptions are
those that are believed to apply with prevention and
treatment programs operating under current levels
of resourcing. This situation was considered to Ix the
baseline scenario for the projections of the future
course of the HIV epidemic.
Alternative Scenarios for Intervention
In addition to the baseline scenario, two alternative
intervention scenarios were identified, representing
the outcomes, in terms of 2 range of behavioural and
therapeutic target levels, of a mid level and a high level
of enhanced intervention. and used to project the
future course of the epidemic in the three countries.
The alternative scenarios were defined in terms of
increases over the period 2005-2010, sustained until
57
Epidemiology & STI
Impact of HIV/AIDS 2005-2025 in Papua New Guinea,
Indonesia and East Timor
Epidemiology & STI
2025, in the extent to which people at risk of HIV
infection were able to undertake preventive a actions
(condom use for sexual intercourse, treatment for
sexually transmitted infections, use of clean needles
and syringes, atiretroviral drugs to stop mother-tochild H I V transinission) and people with HIV infection
were able to obtain effective treatment, which would
have the effect of reducing both disease progression
rates and infectiousness in those treated.
The alternative scenarios were defined to be realistic, in
the sense that they are not extreme departures from the
baseline scenario, and could be feasibly achieved in each
country with enhanced levels of researching, It must
nevertheless be understood that the implementation of
the alternative scenarios would not simply be a matter
of increasing expenditure within narrow programmatic
areas such as condom distribution. Realisation of the
alternative scenarios would require strong political
commitment, as well as expansion of the underlying
infrastructure in various areas, including primary health
care and education. These alternative intervention
scenarios are defined relative to the assumed baseline
scenario, so any inaccuracies in the baseline scenario
will have implications for the validity of the mid and
high level scenarios.
to project the numbers of people who would require
hospital care due to HIV/AIDS, the cost of providing
this care, and the expenditure on antiretroviral drugs.
Prevention expenditure was estimated using available
costing information, combined with estimates of the
numbers of people in subpopulations at risk.
At a community or population level, a quantitative
assessment of impact was undertaken via a
projection of the demographic changes that would
arise as a result of HIV/AIDS. The numbers of deaths
projected under the models were translated into
reduced population sizes and increased numbers of
orphans. Reductions in population sizes were in turn
used to project the workforce impact of HIV/AIDS
on various sectors, including health and education.
In the absence of more specific data, it was assumed
that individuals in all sectors of the work force were
equally likely to be affected.
Estimating the social, economic and
security impacts
Impact on Gross Domestic Product (GDP) was inferred
by applying projected HIV prevalence to a tune
published by the International Labour Organization
that establishes an empirical relationship across a
number of (predominantly African) countries between
HIV prevalence and GDP growth. The economic
impact of the loss of life of working age people was
measured by approximating the value of each year of
life, multiplied by the number of years lost.
Under each of the three intervention scenarios
(baseline, mid level and high level), the
epidemicologicaI model was used to generate
projections of case numbers and deaths, which
provided the means of estimating the future impacts
of the HIV epidemic. Impact was defined at the level
of the individual, the health system, and the broader
community and its functioning.
Analysis of security impacts was largely theoretical,
as few studies have examined this relationship
empirically. It took account of the social and
political context of each country and considered the
potential impact on social cohesion of increased HIV
prevalence, deaths, loss of income and the creation
of orphans.
Limited data were available from the three countries
on the impact of HIV on famlies, but more extensive
information of this kind is available for Thailand
and Several African countries, and was used in a
qualitative way to indicate the household impact,
as measured by the potential loss of incorne and
expenditure of funds arising through HIV-related
illness and death. These impacts are of course in
addition to the personal grief and loss that severe,
fatal illness inevitably brings to families.
Impact on the provision of health care under each of
the three scenarios was assessed by using the model
58
Study Findings
Papua New Guinea
The HIV epidemic in Papua New Guinea has been
largely driven by sexual transmission, both outside
and within marital relationships. According to the
best available data far Papua New Guinea, condoms
are currently used for 20 per cent of contacts
between see workers and their clients, and around a
third of urban women who engage in sex work have
a sexually transmitted infection. There is very limited
use of antiretroviral drugs, either for treatment or
prevention of mother to child transmission.
The high level alternative intenvention scenario
assumes condom use by sex workers and clients
would rise to 40 per cent over the next five years. Over
the same time period, the rate of sexually transmitted
infections would be cut by half and access to anti
retroviral treatment would extend to 80 per cent of
those with AIDS in urban settings. These changes
would be sustained for the following fifteen years,
to 2025. The mid level intervention scenario falls in
between the baseline and the high level scenario.
If Papua New Guinea can implement the high level
intervention scenario, the model projects that there
will be around 200.000 people living with HIV in
2025, or 4 per cent of the adult population, thereby
avoiding hundreds of thousands of cases. Even the
more modest mid-level intervention would prevent
a very substantial number of cases.
The numbers of deaths from AIDS related conditions
will increase rapidly under the baseline scenario.
By 2010 there will have been 85,000 adult deaths,
rising to 300,000 by 2025. Because HIV is sexually
transmitted, the cases of infection, and hence the
deaths, occur largely in the 15-49 year age group.
A high level of deaths in adults of reproductive and
working age would have a number of immediate
impacts.
19,000 children will have lost their mothers to
AIDS by 2010, and this figure will increase to over
117,000 by 2025. Reports from African countries
indicate that orphaned children are more likely
to experience food insecurity and can lose their
housing and inheritances. While traditional support
systems based on extended families and community
structures may absorb orphans, there is growing
concern about the sustainability of such systems.
Furthermore, AIDS orphans are often stigmatised
and discriminated against and they are more likely
to engage in antisocial behaviour.
Under the baseline scenario, the predicted levels
of HIV illness and death will affect economic
performance and place very substantial strains on
national resources. The size of the work force could
decline by as much as 12.5 per cent
by 2025 (Figure 2), with GDP growth
1.3 per cent less than anticipated, due
to the loss of labour.
The enhanced intervention scenarios
would result in very different
outcomes, according to the model.
Under the high level scenario the
cumulative number of deaths to 2025 would be
reduced by over 100,000, and the number of maternal
orphans by some 80,000.
The budgetary impact of HIV in PNG is likely to be
felt most in the health sector, as growing numbers of
people need care and treatment. Under the baseline
scenario, over 70 per cent of medical beds will be
taken with AIDS patients by 2025, but with high level
intervention, the proportion would be closer to 30
per cent (Figure 3).
59
Epidemiology & STI
The epidemic model predicts that if this baseline
scenario continues, Papua New Guinea will see over
half a million people or 10 per cent of the adult
population, having HIV infection by 2025 (Figure 1). An
epidemic that has so far mainly affected households
and families will start to have community wide
consequences, which will ultimately have an impact
on state structures and capacities.
Epidemiology & STI
Under the assumption that government policy
results in around 20 per cent of people with HIV
infection being treated with antiretroviral therapy
and that all are treated for opportunistic infections,
the additional medical costs to the budget under
the baseline scenario could be as high as PGK 114
million (AUD 50 million) per annum at current prices
by 2025.
These costs would be cut by dose to PGK 70 million
(AUD 30 million) under the high level intervention
scenario, because there would be far fewer people
with HIV infection. The expansion in preventive
interventions required to achieve these reductions
in transmission will cost an additional PGK 27
million (AUD 12 million) by 2010, and PGK 41
million (AUD 18 million) by 2025, but from a purely
economic perspective these figures are still far
lower than the amount being saved in the costs of
treatment and care.
Indeed, the model predicts that the expenditure on
prevention will plateau over time, while the savings
on the costs of treatment and care continue to
climb.
The key to HIV prevention in Papua New Guinea is a
reduction in sexual transmission of the virus. Many
new infections are taking place through sexual
contacts outside marriage, that often involve the
provision of money, goods or services by men to
women in exchange for sex. Under the baseline
scenario, up to 25 per cent of women who engage in
such contacts will have HIV infection by 2025, but if
the high level scenario could be implemented across
the country, this proportion would stay below 10 per
cent (Figure 4).
60
The benefits of reducing transmission among
women who engage in sex work would extend well
beyond this population group to their male clients, of
whom than one million, and to the women who are
the marital partners of these clients. By 2010, under
the baseline scenario, 25,000 women who arce not
involved in sex work will be HIV positive, and the
figure will rise to over 120,000 by 2025. However, if
the high level intervention scenario
is achieved, this total would be cut
in half.
There are those who have argued
that the best way to eliminate HIV
transmission would be to eliminate
sexual relations outside marriage,
but long experience tells us that
this is all unrealistic objective.
The combination of low levels of
condom use, high rates of sexually
transmitted infections, and women’s
lack of authority to negotiate safe sex
both within and outside marriage presents particular
challenges for HlV prevention in Papua New Guinea.
At the levels of prevalence and consequent death
rates projected udder the baseline scenarios HIV
infection has the potential to undermine governance
and increase poverty in the community. The urgent
call on care and treatment resources will result
in a diversion of goverment efforts away from
development of the very infrastructure that is
necessary for the delivery of HIV interventions and
relief of poverty and human security. Reduced state
capacity has the potential to provoke challenges to
government at stability which may become an issue
of wider regional security.
It is important to emphasise that achievement of the
high and even the mid response scenario will need
financial resources, multilevel, and multi-sectoral
political support, with legislative, social and policy
changes. In the long term, the sustainability and
effectiveness of enhanced interventions will depend
on strengthened health services, infrastructure,
and ongoing provision of the necessary infomation
and tools to stop the spread of HIV. This requires
measures to improve the social status of`women
addressing mens roles in prevention, challenging
stigma, providing support for those living with HIV
and sex education including relationship skills for
young people. Facing an epidemic of the magnitude
predicted by the models using the best available
data, Papua New Guinea still has the opportunity to
make a big difference in its course through decisive
leadership.
Indonesia
In most of Indonesia it appears that the HIV epidemic
is concentrated in urban areas, and largely related
to the practices of drug injection and, to a lesser
extent, commercial sex. Prevalence among the wider
population remains very low. Clean needles and syringes
are consistently used by only about 12 per cent of those
who inject, and condom use by sex workers and their
clients covers only about a quarter of contacts.
In Papua, a very different pattern of transmission is
evident, with the dominant source of infection being
sexual, both within and outside marital settings, and
a much greater spread in rural areas. The population
prevalence of infection may have already reached 1
per cent. About a third of commercial sex contacts
in urban areas of the province involve condoms,
but usage is far lower its rural settings. There has
so far been very limited use of antiretroviral drugs
in Indonesia, either for treatment or prevention of
mother to child transmission.
The epidemic model predict that if this baseline
scenario continues, there will be around 1,95 mullion
people living with HIV infection by 2005, made up
of over I45,000 in Papua and 1.85 million elsewhere
(Figure 5). HIV prevalence among adults in Papua
would reach 7 per cent, while in the rest of the country,
it would exceed 1 percent, thereby satisfying the
international definition of a generalised epidemic.
The future would be very different for Indonesia under
the high level enhanced intervention scenario. Over the
five years to 2010, consistent use of clean equipment
would expand to 36 per cent of those who inject drugs,
condom use by sex workers with their clients would rise
to 60 per cent, and the rate of sexually transmissible
infections wold be cut by half. Antiretroviral treatment
would become available to 80 per cent of people with
AIDS. These changes would be sustained for the following
fifteen years, to 2025. The mid level intervention scenario
falls in between the baseline and the high level scenario.
If Indonesia can implement the high level intervention
scenario, the model projects that there will be less than
500,000 people living with HIV in 2025, and that over
1,4 million infections will thereby have been avoided.
PrevaIance will have been maintained below 0,1 per
cent nationally, and at 3 percent in Papua- Even under
the more modest mid-level intervention. Indonesia can
prevent one million infections by 2025. The effect of the
high level scenario is particularly dramatic for provinces
other than Papua, where transmission outside the
context of injecting drugs and sex work could be largely
eliminated, because the background levels of infection
are currently very low.
Among injecting drug users, the baseline model
indicates that HIV prevalence will reach nearly 40
percent by 2025 but it could be kept closer to 15
per cent if the high level intervention scenario
is implemented, with some 80,000 fewer people
acquiring the infection through their drug injecting
practices (Figure 6). It is important to note that HIV
infection in people who inject drugs can result in
transmission to their sexual partners, and to their
children, and can ultimately be a cause of ongoing
transmission in the wider population.
Sex workers in all provinces will be highly affected
by rising HIV rates under the baseline scenario. In
particular, by 2025, a third of the women predicted
to have HIV under the baseline scenario in Papua
will have acquired the infection through sex work.
The models indicate corresponding increases in
prevalence among men who are clients of sex worker,
61
Epidemiology & STI
On the outer hand, enhanced responses, even under
the mid level scenario, can ultimately result in savings
because they will save thousands of lives through
reduced transmission rates, avoid government
expenditure through a reduced need for care and
treatment and allow for greater productivity and
development opportunities.
Epidemiology & STI
reaching 10 per cent by 2025 in Papua, and in turn,
transmition to the wives of these clients.
In other provinces of Indonesia. HIV prevalence
among women who have engaged in sex work will
increase from 4 per cent to nearly 23 per cent by 2025
and in their male clients the rise will be from 0,5 to
3 per cent. However, under the high intervention
scenario, prevalence in sex workers could be kept to
below 4 per cent nationally, and 20 per cent for Papua
Figure 7). Although the projected prevalence for sex
workers outside Papua seems relatively low, even
under the baseline scenario, the large population
base in Indonesia means that there is a potential for
extensive transmission.
In Indonesian provinces other than Papua, the
projected HIV prevalence will not be high enough to
have a measurable effect on population structures.
Nevertheless, under the baseline scenario, the
number or deaths nationally will be very large, with
adult deaths of over 300,000 projected by 2010 and
1,4 million by 2025. If the high level response can
be implemented the total number of death will be
cut to 600,000. For Papua, the mortality rate will be
high enough to affect population structure. Under
the baseline scenario, there will be a measurable
decline in population growth, with the age group
20-49 years particularly affected. By 2025, there will
be 5 per cent fewer people of working age in Papua
than there would have been if the HIV epidemic
had not occurred. However, under the high level
intervention, this population loss would be reduced
to 3,3 per cent.
62
Overall effects of HIV-related
mortality on the Indonesian
economy will therefore be limited,
except in Papua, which is predicted
to have experienced 84,000 adult
deaths due to HIV/AIDS by 2025
under the baseline scenario. As most
of these deaths will have occurred
in the 15-49 year age group, they
will have a particular effect on the
largely agricultural workforce, and
a third of deaths will be in adult
women. The impact will also be
heavy on children in Papua, watt
33,000 matternal orphans by 2010
rising to 66,000 by 2025. Orphaning may reduce
school attendance if children are required to provide
economic support by tending gardens and other
activities. Land inheritance may become an issue,
and HIV stigma may further marginalise orphans.
Nationally, the sectoral and budgetary consequences
of increasing HIV prevalence are likely to be felt most
heavily in the health sector, as growing numbers of
people need treatment. In Indonesia, by 2025, the
baseline model predicts that 27 per cent of the public
medical beds will be filled with people with AIDS,
and in Papua the proportion will be over 80 per cent
(Figure 8). Under the high level response scenario,
this figure for Papua would fall to 40 per cent.
If the epidemic continues without an increased
prevention effort, the costs of caring for those with
opportunistic infections and providing antiretroviral
drugs will continue to rise. By 2025 treatment costs
are predicted to be over IDR 3,210 billion (AUD 450
million) at current prices under the baseline scenario,
and assuming that there is a continued expansion
of treatment access. An additional investment in
prevention of around IDR 357 billion (AUD 50 million) per
annum would result in a saving of some IDR 2,854 billion
(AUD 400 million) in the costs of treatment and care.
At the levels of HIV prevalence projected for Indonesia
as a whole. the social and economic impacts will
be felt most strongly in the households of those
directly affected. Women within these households
will experience particular vulnerability. Under the
In terms of the governance and security impacts
of HIV, major infrastructural and state service
advancements have been achieved in Indonesia since
independence, but many people remain economically
vulnerable. The impact of rising HIV prevalence may
in turn increase instability if it increases poverty
and threatens food security in an environment that
is strongly dependent on subsistence agriculture.
In Papua, the destabilising impact on communities
of high HIV prevalence may escalate tensions and
contribute to conflict.
In conclusion, under the baseline scenario, Indonesia
will be facing a generalised epidemic by 2025, with
prevalence exceeding 1 per cent of adults, and
in Papua an epidemic on a much larger scale is
envisaged. The increasing care and treatment costs
and the rising demands on the health sector will be the
most direct systemic effects, with the greatest social
and economic impacts being felt at the household
level. Nevertheless,
with
appropriate
political
support,
legislative and policy
changes, and the
financial resources,
the HIV epidemic
in Indonesia can
be
substantially
mitigated, provided
a response can be
developed
that
provides
for
a
real expansion in
prevention coverage
among
people
who inject drugs and female sex workers and their
clients. In Papua, a high level response will inevitably
depend on culturally appropriate HIV prevention
programmes for indigenous people.
East Timor
Despite facing many health challenges, East Timor
has so far had very limited experience of HIV/AIDS.
The available survey data suggest low levels of
condom use and high levels of sexually transmitted
infections in women who engage in sex work.
Under the baseline scenario, the prevalence of HIV
in East Timor will increase to about 0,6 per cent by
2025, resulting in around 5,000 people living with
HIV (Figure 9). Thus, even under the baseline scenario,
HIV prevalence in East Timor is not predicted to reach
the defined threshold for a generalised epidemic.
Nonetheless, under this scenario there will be a
cumulative total of 2,200 adult deaths and around
400 maternal orphans by 2025, The epidemic is
predominantly urban.
Enhanced intenventions in East Timor would be
aimed at increasing condom use by sex workers
and their clients to around 30 per cent, and halving
the prevalence of sexually transmitted infections
in sex workers- Under the baseline scenario, HI V
prevalence among sex workers well increase from
just over 3 per cent in 2005 to 34 per cent in 2025,
and the prevalence in male clients of sex workers
63
Epidemiology & STI
baseline scenario, even though the prevalence
overall among women is projected to be less than
0,5 per cent, there will nonetheless be 200,000 nonsex worker women who are HIV-positive. In Papua,
the projected prevalence in women will be nearly
ten times higher, with 40,610 women HIV-positive
(4,3 per cent prevalence), and 21,000 deaths by 2025.
The increases in HIV will place greater economic
pressure on women and the economic imperative to
undertake sex work may also increase.
Epidemiology & STI
with rise to over one per cent by 2025. The high level
response scenario would see prevalence among
women involved in sex work staying below 5 per cent,
with corresponding reductions in prevalence among
their clients, and the marital partners of clients.
Among men who have sex with men the prevalence
will reach 6 per cent by 2025 under the baseline
scenario, but if condom use rises to cover 30 per
cent of sexual acts, the projected prevalence can be
expected to remain close to 2 per cent.
The East Timorese are building up a health system
from a limited base. The high level of poverty in East
Timor has particular implications for women, who
also fare poorly compared to men in a number of
indicators. While few women who are not sex workers
will be infected with HIV in the next twenty years,
64
HIV has the potential to increase the vulnerability of
those affected.
With the availability of Global Fund to Fight AIDS,
Tuberculosis and Malaria monies and the conclusion
of the 2002-2005 HlV/AIDS/STI National Strategic
Plan, East Timor is now at a critical junction and
poised to translate lessons learnt from the previous
stategic plan, and the additional funding, to maintain
its current low HIV prevalence.
Key to the success of the high response is the
integration of HIV prevention, care and treatment
activities within a health sector-wide approach. Such
integration means the health sector is adequately
equipped, in terms of staffing, skills and procurement
and distribution systems to undertake an expanded
and comprehensive HIV response.
Executive Summary
Epidemiology & STI
Trends of Risky Behaviors for HIV/STI in Indonesia
(Results of IBBS 2007)
Ministry of Health, Republic of Indonesia (Depkes RI)
www.depkes.go.id
National AIDS Commission (KPA)
www.aidsindonesia.or.id
Family Health International – Aksi Stop AIDS (ASA) Program
www.fhi.org
65
Trends of Risky Behaviors for HIV/STI in Indonesia
(Results of IBBS 2007)
A good understanding of dynamics of HIV-AIDS
epidemic in Indonesia will help in implementing
the national HIV-AIDS control program effectively.
Dynamics of the epidemic can be defined as the recent
pattern in the country and its trends in the future.
Indonesia is classified as a concentrated epidemic,
which means that the spread and dynamics are
mostly influenced by certain sub-populations
(Most-At-Risk Groups/ MARGs) through their risky
behaviors. Nevertheless, in responding to the
epidemic, programs tend to overlook the chance of
HIV spread from MARGs to their sexual partners, who
probably do not have risky behaviors.
Surveillance is a crucial activity in defining, preventing
and controlling the epidemic, particularly documenting
the changing trends of risky behaviors among MARGs.
behavior among the MARGs, their understanding
about HIV transmissions had improved, although,
there was no significant change in their understanding
on how to prevent HIV transmission.
The findings also revealed the fact that percentage
of misconceptions about HIV transmission among
most of the MARGs increased, except for IDUs and
transvestites. The percentage decreased among
these two groups.
This fact endorses health planners to review
the IEC materials. It needs to employ strategic
communication. By having so, it is expected that these
sub-populations will not just educate themselves
more regarding HIV transmissions and its prevention,
but also to bring the knowledge into practice.
Did trends and patterns of risky behavior change?
The Ministry of Health of Indonesia conducted the
Integrated Biological Behavioral Surveillance (IBBS)
to better understand the HIV epidemic in Indonesia.
Importance is given to the findings of IBBS 2007 since
it incorporated behavioral and biological aspects of
MARGs, on HIV and STI. The ministry ensured the
quality of IBBS data collection and management.
Do dynamics in demography of MARGs exist?
Youth still occupied the majority of MARGs. These
groups were defined as female sex workers,
transvestites, clients of transvestites/sex workers,
IDUs, and MSM.
No major changes were observed in the age
distribution of these sub-populations. However, the
initiating age of young people using injecting drugs
was 25 years and above; quite different from IBBS
data presented two years ago. This phenomenon
possibly occurred due to nonexistence of new young
IDUs or the existing young IDUs had quit using the
drugs or they had died.
Sexual behavior with non-permanent sex partner, with
commercial sex worker or casual sex partner appears to
have a pivotal role in future trend of HIV transmission. It
will replace the existing trend where injecting drug use
was the dominant factor for HIV transmission.
By mean value, trend for clients of sex workers did
not alter significantly. It ranged between 30-60% for
buying sex during the past one year. However, there
was significant increase of buying-sex activity among
the clients.
The number of clients of female sex workers
significantly increased, particularly clients of direct
female sex workers. This finding is contradicting the
findings among indirect female sex workers and
transvestites.
Did level of knowledge about HIV transmission
increase?
The findings showed two different patterns of
sexual activities among the sub-populations. Firstly,
there was significant decrease of non-commercial
sexual behavior among sex workers and their
clients. Secondly, there was significant increase
of non-commercial sexual behavior among MSM,
transvestites, and IDUs.
IEC brought good news to HIV program implementers.
After intensive work in promoting healthy life and
Finally, the results demonstrated that risky sexual
67
Epidemiology & STI
Executive Summary
Epidemiology & STI
behavior (commercial or casual) among MARGs
remained high. Based on those findings, focus of
communication strategies needs to be sharpened.
Thus, it is expected to bring change in the risky
behavior of MARGs; especially a decline in the
number of sexual partners in the future.
Is it true that injecting behavior has not altered yet?
The findings revealed that there was significant
decline in sharing of unsterile needles among IDUs;
suggesting that the risk of HIV transmission among
this group was decissively decreasing. On the other
hand, the injecting behavior among commercial sex
community, like MSM and transvestites, can increase
the transmission risk through sexual and injecting
drug behaviors. An appropriate response needs to
be planned to control the double risks.
Did condom use increase?
Among commercial sex workers, trend for condom
use during the last commercial sex activity showed
significant increase. Nevertheless, the overall figure
of condom use for commercial sex activity was not
promising. Less than 50% of the surveyed population
was still practicing sexual intercourse without condom,
both with commercial and casual sex partners.
Is it true that young people tend to practice risky
behaviors?
Although HIV/AIDS epidemic in Indonesia is still
concentrated in population-at-risk, behavioral
surveillance is a necessity. By doing so, risk of HIV
transmissions can be controlled as early as possible.
That is likely to happen when the young people are
given education about healthy behaviors; avoid
injecting drugs and pre-marital sex.
Level of knowledge about HIV transmission among
youth remained low. There were large numbers of
them who had misconceptions about HIV/AIDS.
Trend of sexual behavior among young boys showed
double increase to 14.6%, while among young girls
it was 6.4%.
Despite the low figure of injecting drug use among
young boys, there was significant escalation of young
girls using injecting drugs.
From IEC point of view, students tend to show
increase in attempting risky behaviors. This was
despite massive information about HIV/AIDS and
its transmission that has already been disseminated
through schools.
Did the programs reach majority of MARGs?
There was significant increase in number of peopleat-risk being educated through discussions or
distribution of IEC materials. The national HIV control
programs need to reach men who are potential
buyers of commercial sex. Until recently, 70% of men
with risky behaviors have ever received IEC materials,
but only 20% of these men were exposed to educative
discussion sessions.
Conclusion and Recommendation
Besides that, number of people-at-risk who opted for
testing for HIV showed an increase. Yet, among the
MARGs, the total percentage did not reach half of
the total population-at-risk, except for transvestites
group. Efforts for scaling up the number of HIV testing
and counseling of MARGs have to be leveraged
in terms of increasing the knowledge of MARGs
about HIV transmissions, and of administering these
persons to ARV drugs.
It is expected that, by extending educational efforts
through IEC and by more strategic approaches
towards the MARGs, behavior change among these
people will occur.
The national HIV/AIDS control activities have been
increased during the past years. Yet, it could not
bring down the risk of transmission of new infections
among MARGs.
The spread of HIV can only be prevented when these
sub-populations alter their risky behaviors.
For STI, prevention and treatment of cases must
be strengthened. The population-at-risk should
have easy access to health care providers. Condom
promotion must also be strengthened so as to
improve the HIV control program.
Is it true that HIV and STI increased among the MARGs?
In some areas, where STI services were provided
adequately to commercial sex workers, there was
significant reduction of STI cases, such as gonorrhea
and chlamydia. However, STI like syphilis remained
high in areas where STI services were inadequate.
68
In addition to the above recommendations, quality
of the control program needs to be assured. Thus,
impact of the program can be seen when risky
behaviors are decreasing and new transmissions are
prevented.
Ministry of Health, Republic of Indonesia (Depkes RI)
www.depkes.go.id
National AIDS Commission (KPA)
www.aidsindonesia.or.id
Family Health International – Aksi Stop AIDS (ASA) Program
www.fhi.org
Statistics Indonesia (BPS)
US Agency for International Development (USAID)
69
Epidemiology & STI
HIV/STI Integrated Biological Behavioral
Surveillance (IBBS) among Most-At-Risk Groups
(MARG) in Indonesia, 2007
Surveillance Highlight: Injecting Drug
Users
Injecting drug users (IDU) are particularly
vulnerable to transmission of HIV because sharing
contaminated drug injecting equipment transmits
the HIV virus more efficiently than any other mode
of transmission. Since initial data indicating 19%
prevalence among IDU in 1999, HIV prevalence
has been consistently rising in this population subgroup, and represents the highest prevalence of
HIV among identifiable population sub-groups in
Indonesia. This summary presents key findings of
the IBBS 2007 from two (2) cities from which only
behavioral survey data were gathered (Semarang
and Malang) and four (4) cities from which both
biological and behavioral data were gathered
(Medan, Jakarta, Bandung, and Surabaya). Official
estimates for 2006 indicated there were 190,000 248,000 IDU in Indonesia in that year.
Key Finding 1: Between 43%-56% of IDU in four cities
were infected with HIV.
IDU continue to have the highest prevalence of
HIV among most-at-risk-groups in Indonesia. The
prevalence of HIV was 55-56% in the three of the four
cities in which biological data were collected, but
somewhat lower in Bandung (43%).This homogeneity
is not accounted for by mobility of IDU between
cities, as few IDU reported having traveled between
provinces to inject (see data table).
HIV prevalence among those who injected drugs
for two years or less was substantially lower
than among those who had injected drugs for
more than two years, suggesting that many HIV
infections among IDU can be prevented if IDU
are reached by interventions early. In Jakarta and
Semarang, about a quarter of the IDU have been
injecting for less than a year, whereas in Malang
only 4% were new injectors (see data table). These
variations in turn-over by city are important to
understanding the differential potential impact
of prevention efforts across cities. Few IDU are
female (1-8%).
Key Finding 2: Needle exchange programs (NEP) have
achieved high coverage in some cities, and these cities
tend to have lower prevalence of injection equipment
sharing among IDU. However, the number of needles
being distributed appears to be insufficient.
The proportion of IDU receiving clean needles and
syringes from a Needle Exchange Program (NEP) in
the last week, an indicator of NEP coverage, ranged
from 98% in Medan to 33% in Surabaya (Figure 2).
The cities that have achieved high coverage of IDU
through NEP tend to have lower proportions of IDU
reporting having shared a needle in the past week.
As shown in Figure 3, distribution of clean needles
through NEP has risen dramatically since 2004, and
other than in Jakarta, substantial reductions in sharing
needles have occurred over the same period.
Despite increased coverage, needle exchange
programs do not appear to be distributing a sufficient
quantity of needles to clients, as 13-72% of IDU
(depending upon the city) receiving needles from a
NEP in the week prior to the IBBS also reported having
sought needles from other sources during that week
(see data table). Needles are often discarded unsafely,
which puts others persons at risk of HIV infection
through accidental needle sticks (see data table).
71
Epidemiology & STI
HIV / STI Integrated Biological Behavioral
Surveillance (IBBS) among Most-at-Risk Groups
(MARG) in Indonesia, 2007
Epidemiology & STI
Key Finding 3: Sizeable numbers of IDU are being
reached by methadone substitution programs, but
many IDU reached by such programs continue to inject.
Between 8% (Malang) and 54% (Semarang) of IDU
received a HIV test result in the past year (see data
table). However, the fact that no differences in
behaviors were observed when comparing IDU who
had been tested for HIV and those who had not (data
not shown) suggests that HIV counseling needs to be
strengthened.
Key Finding 6: IDU reported having had sex with multiple partners, including regular/permanent partners, casual partners and female sex workers. However, few reported having sold sex.
Methadone substitution programs covered sizeable
numbers of IDU in Indonesian cities ranging from
17% in Jakarta to 88% in Malang (see data table).
However, most of those who received methadone
maintenance therapy (MMT) in the past year were
still injecting in the past week, which might reflect
irregular supply of methadone at distribution sites,
inadequate dosage, or both.
Key Finding 4: The prevalence of STI among IDU is low
compared to other high risk men in Indonesia.
IDU have lower prevalence of STIs than other high
risk men. However, the prevalence of Chlamydia
Trachomatis among IDU was moderately high,
ranging between 5 and 6% in the four cities.
Key Finding 5: Less than 30% of IDU in six cities had
been tested for HIV in the year prior to the 2007 IBBS
survey. Knowledge of HIV status does not seem to
have influenced behavior.
72
In the past year, between 38% to 59% of the IDU
in the six cities from which behavioral data were
collected had a regular partner with whom they had
sex, and 20% to 60% had casual partners. In addition,
9% to 54% of male IDU had sex with a female sex
worker (FSW) in the past year. Selling sex was seldom
reported by IDU (19% of female and 3% of male
IDU).
Key Finding 7: Unprotected sex seems to be the norm
among IDU, irrespective of type of partner.
Inconsistent use of condoms was reported by the
majority of IDU in all cities and with all types of
partners. Through unprotected sex, especially with
Epidemiology & STI
FSW, IDU contribute in important ways to the spread
of HIV in Indonesia. About half of male IDU visited
FSW in the year prior to the survey, and those who
did so reported having had sex with an average of
four (4) FSW. It is estimated that IDU had 380,000
unprotected sex encounters with FSW in the last
year, a figure that nearly equals the estimated total
number of FSW in Indonesia.
73
Epidemiology & STI
Conclusions and Recommendations
Data from the 20071885 among most at risk groups
(MARG) in Indonesia provide insights into the current
status of the HIV/AIDS epidemic among intravenous
drug users (IDU), as well as data with which to update
trends in HIV-related biological and behavioral
indicators over time. These data thus contribute to the
growing, but still limited, evidence base for decision
making concerning HIV/AIDS in Indonesia. Conclusions
and key recommendations concerning IOU include the
following:
In view of very high HIV prevalence among
IDU and continued high prevalence of
risky injecting and sexual behaviors, harm
reduction interventions need to be expanded
and intensified as a matter of high priority.
There are more injecting drug users infected
with HIV than in any population sub-group in
Indonesia. IDU get infected primarily through
needle sharing. While FSW serve as the primary
vector for the dissemination of HIV to the
Indonesian general population, IDU are at present
the core reservoir of infections in the country. A
substantial proportion of IDU had been jailed
at one time or another, which both contributes
to the spread of HIV among prison inmates and
poses a risk to the general population when
HIV-positive inmates are released back into the
community. Taken in the context of earlier HIV
sentinel surveillance data from the Ministry of
Health, data from the IBBS 2007 provide little
in the way of evidence that the HIV epidemic
among IDU is abating. However, because many
IDU remain uninfected after two years of injecting
drugs, prevention programs can potentially
prevent a substantial number of infections if IDU
are reached early enough.
Comprehensive efforts that reach critical
coverage levels (70%-80% of IDU) are urgently
74
needed to slow down the progression of HIV/
AIDS in the ranks of IDU. Key components
should include access to accurate information,
comprehensive distribution and recovery of
needles, coordinated methadone maintenance
programs, behavior change communications/
interventions, condom promotion, access to
primary health care, and access to voluntary
counseling and testing. Priority attention should
be given to needle exchange programs and
methadone maintenance therapy (MMT).
Needle
exchange and methadone
maintenance programs need to be both
expanded and strengthened in order to have
their intended impact.
Needle exchange programs have greatly
expanded their coverage in recent years, which
is likely the primary cause of the reduction
in needle sharing observed in the 2007 IBBS
data. However, coverage remains low in some
cities, and programs appear not to provide a
sufficient number of needles-syringes, resulting
in sustained injecting risk. The factors underlying
provision of insufficient quantities of needles
need to be determined and corrective actions
taken immediately.
Insufficient frequency of safe disposal of used
needles and syringes is also a concern, likely due
at least in part to concern among IDU over being
caught by police with traces of heroin in needles
being returned. Stronger coordination between
public health and law enforcement authorities
is needed in order to provide sufficient “space”
for effective HIV/AIDS prevention measures such
as needle exchange programs. Steps toward
achieving this might include education of local
police on public health issues related to drug
use and continued/stronger advocacy to law
enforcement authorities.
In view of high HIV prevalence among IDU,
coverage of HIV counseling and testing needs
to be rapidly expanded.
There are a sizeable number of IDU in Indonesia
who are infected with HIV but are not aware of
their infection. This both precludes them from
receiving adequate care, support and treatment
in the event that they are HIV positive and reduces
incentive to take action to prevent infecting
others, including spouses. Coverage of HIV
counseling and testing among IDU has increased
somewhat in recent years, but progress must
be accelerated further. Operations research to
identify barriers to acceptance of HIV counseling
and testing among IDU should be undertaken to
guide program efforts to increase coverage.
Consistent condom use among IDU remains
low, and strong condom promotion efforts
targeting IDU are needed.
IDU are sexually active and tend to have multiple
partners. One-half of IDU regularly have sex with
FSW. With all types of partners, IDU usually have
unprotected sex. Because of high HIV prevalence
among IDU, their frequency of unprotected
sex is likely to play an important role in fueling
the epidemic among FSW, who in turn are
positioned to disseminate the virus to the general
population.
IDU need behavior change communications
interventions that focus on safe sex and partner
reduction, as well as interventions maximizing
their access to condoms. Despite the moderate
prevalence of STI among IDU, STI screening
should be intensified among IDU combined with
HIV pre-test counseling with opt-out for HIV
testing.
Increased attention needs to be directed to
the needs of spouses and regular partners of
IDUs.
Spouses and female sexual partners of IDUs in
Indonesia are at elevated risk of HIV infection
because of high HIV prevalence among IDUs and
low levels of condom use. Although establishing
contact with spouses/partners of IDUs is
challenging, it is essential that greater efforts be
made to increase program coverage to provide
spouses/partners with accurate information
on HIV/AIDS, prevention measures, and care,
support and treatment for IDU LWHA, as well
as to provide psycho-social and other types of
support for spouses/partners themselves.
Priority attention should be directed to IDUs
in prisons.
Because access to clean needles and condoms
is restricted in prisons, such facilities provide
an ideal setting for the rapid spread of HIV
among prison inmates, particularly among
IDUs. Program efforts should emphasize HIV
prevention educational and behavior change
efforts, introduction of methadone maintenance
therapy (MMT), access to a reliable supply
of condoms, and access to STI management,
VCT, HIV care, support and treatment, and
management of opportunistic infections (OIs,
especially tuberculosis) services.
Surveillance Highlight: Female Sex
Workers
Unprotected sex between female sex workers
(FSW) and their clients is the second most common
route of HIV transmission in Indonesia after sharing
of contaminated drug injecting equipment. This
summary presents key findings of the 2007 IBBS from
eight provinces for two groups of FSW: Direct FSWs
(DFSW), who consist of brothel- and street¬-based
sex workers, and Indirect FSWs (IFSW) – women
working in karaoke bars, massage parlors, etc. Official
estimates are that there were 95,000-157,000 Direct
FSWs and 85,000 -107,000 Indirect FSWs in Indonesia
in 2006.
75
Epidemiology & STI
Coverage of methadone maintenance therapy
(drug substitution) has also increased significantly
in recent years, but many IDU on MMT continue
to inject, thus reducing program impact.
Substitutive therapies should be included in a
coordinated comprehensive system of primary
health care and psycho-social counseling, with
an adequate monitoring system, to ensure that
the clients receive a sufficient dose of drug
substitute.
Epidemiology & STI
Key Finding 1: Depending upon the province, 6-16% of
Direct FSWs and 2-9% of Indirect FSWs were infected
with HIV. The proportion of FSWs infected in their first
six months of selling sex is alarmingly high.
Among Direct FSWs, the highest prevalence of HIV
was recorded in Tanah Papua and Bali, whereas
the highest prevalence among Indirect FSWs was
recorded in Batam and Jakarta. Among both Direct
and Indirect FSWs, the prevalence of HIV among those
new to sex work was almost as high as the prevalence
among FSWs with longer experience of sex work,
indicating that FSWs get infected very quickly after
initiating selling sex. Every six months, one-third to
one-half of Direct FSWs and 25% of Indirect FSWs are
newcomers to the sex business (see data table).
in cities such as Medan and Jakarta is dangerously
high.
Overall, about 50% of FSWs reported using medical
services (public or private) when symptoms of STI
occur (see data table). The provinces with lowest
prevalence of Chlamydia or gonorrhea were the
provinces with the highest proportions of Direct
FSW receiving a check-up at an STI clinic in the past
month. However, about half of the Direct FSWs in
these provinces were still infected, even when more
than 70% received monthly STI check-ups. Use of STI
services bears no relationship with the prevalence
of STI among Indirect FSWs. These findings suggest
rapid rates of re-infection, ineffective treatment
services, or both.
Key Finding 2: The prevalence of sexually transmitted infections (STIs) was very high among Direct
FSWs and moderately high among Indirect FSWs.
There is little evidence of declining STI prevalence
among FSW.
FSWs infected with STIs have elevated risk of both
transmitting and acquiring HIV. Between 36% of
Direct FSWs (in East Java) and 60% (in Jakarta) were
infected with at least one of these three STIs, while
between 29% of Indirect FSWs (in East Java) and
39% (in Jakarta) were so infected. Chlamydia is the
most common STI among both groups of FSWs. The
prevalence of Chlamydia and gonorrhea are among
the highest recorded in Asian countries, and the
prevalence of active syphilis among Direct FSWs
Surveillance data from four (4) cities for which multiple
STI surveillance data points are available (Banuwangi,
Jakarta, Medan and Semarang) do not indicate
dramatic changes in STI prevalence among FSW
between 2002 and 2007 (Figure 3). The prevalence of
Chlamydia in the four cities declined slightly between
2005 and 2007, but had risen slightly between 2003
and 2005, and only in Banuwangi is a clear downward
trend in Gonorrhea prevalence apparent. Analysis of
data from all cities for which STI prevalence data are
available for 2005 and 2007 support the conclusion
of slightly declining prevalence of Chlamydia and
gonorrhea during this period (data not shown).
76
Key Finding 3: FSWs’ weekly number of clients is
fairly small.
Apart from Bali, where half of the Direct FSWs had
at least 14 customers in the past week, the median
number of clients in the past week among Direct
FSWs ranged from 5 to 8 (see data table). Indirect
FSWs tended to have even fewer weekly clients, with
medians ranging from 1 to 6. This relatively small
number of commercial partners suggests that regular
users of FSWs play a critical role in maintaining high
prevalence of STI among FSWs.
Key Finding 4: Consistent condom use in commercial
sex in 2007 was low and shows no signs of having
increased during the 2002-2007 period. Moreover,
the reported frequency of condom breakage is
extremely high, meaning that the reported condom
use figures overstate the actual level of protection
being provided.
The use of condoms in commercial transactions
between FSW and clients in Indonesia appears to be
increasing slowly, but steadily, over time (Figure 4).
The proportions of FSW using condoms at last sex
and consistent use with clients in the past week both
trended upward between 2002 and 2007. However,
consistent condom use in commercial sex remains
insufficient to significantly disrupt HIV transmission
between FSW and their clients and vice versa.
Furthermore, these data, which are aggregated over
10 cities, mask important variations from city to city
(see data table), and in particular falling rates of
consistent condom use in some cities – for example,
in Jakarta. So while the overall trend is upward,
intensified efforts to significantly increase consistent
condom use are needed in all cities.
Key Finding 5: Too few FSWs know that condoms can
protect them against HIV.
Depending on province, between 17% and 54% of
Direct FSWs and 21% to 49% of Indirect FSWs did
not know that condoms protected them from HIV
transmission during vaginal or anal sex (see data
table) Furthermore, the decision to use a condom
often appears to depend on external factors, as 60%
of the Direct FSWs who had used a condom at last sex
did so because either the customer or the manager
requested it.
Key Finding 6: Few FSWs are drug injectors. Drug
abuse only affects a small proportion of FSWs, but
use of methamphetamines is reported by sizeable
proportions of FSWs in some cities.
Injecting drug use and commercial sex is a particularly
dangerous combination, with the potential to rapidly
accelerate the progression of HIV/AIDS epidemic in
the ranks of FSWs. Fortunately, few FSWs reported
injecting drugs (see data table). However, 32% of
Indirect FSWs in Batam and 19% in Jakarta reported
using methamphetamines in the past 3 months.
While less dangerous for HIV transmission than
injecting drugs, such high use of methamphetamines
is likely to impair FSWs’ intent and ability to negotiate
condom use with clients, and thus should be
monitored closely.
FSWs also reported remarkably high rates of condom
breakage during the past month - between 8% and
77
Epidemiology & STI
28% among Direct FSWs in the cities covered in the
2007 IBBS and from 6% to 19% among Indirect FSWs,
exposing yet more FSWs and their clients to the
risk of HIV transmission (see data table). These high
reported breakage rates indicate high prevalence of
improper condom use, inadequate condom quality,
or both.
Epidemiology & STI
78
With a rising number of FSWs infected with
HIV, interventions focused on HIV prevention
need to be expanded and intensified.
After injecting drug use, commercial sex makes
the largest contribution to HIV infections in
Indonesia. Taken in the context of earlier HIV
sentinel surveillance data from the Ministry
of Health, data from the IBBS 2007 among
MARG provide little in the way of evidence
that the HIV epidemic among FSWs is abating.
If anything, it may be accelerating. Given the
low prevalence of condom use, FSWs play a
critical role in transmitting HIV to the general
population. Indeed, it is anticipated based upon
epidemiologic modeling that sexual transmission
driven by commercial sex will soon or may
already have replaced injecting drug use as the
primary driving force of the HIV/AIDS epidemic
in Indonesia.
The 2007 data suggest that young FSWs new to
the commercial sex trade tend to acquire HIV
infections quickly. Those newly infected are those
most likely to transmit the virus because of a high
viral shedding. With high rates of turnover of
FSWs observed in most cities, FSWs at the highest
risk of transmitting HIV to their male partners
are constantly being replenished - a dangerous
situation indeed.
Comprehensive efforts that reach critical
coverage levels (70%¬-80% of FSWs) are urgently
needed to slow down the progression of the
HIV/AIDS epidemic in the ranks of FSWs. Key
components should include access to accurate
information, behavior change communications/
interventions, condom promotion, secure access
to condoms, access to effective treatment of
STIs, and access to HIV voluntary counseling
and testing. Priority attention should be given
to providing information to and intensively
supporting consistent condom use among those
new to the sex business.
The prevalence of STIs among FSWs in
Indonesia is very high, and interventions
aimed at controlling STIs among FSWs to date
have been ineffective.
STIs are considered by epidemiologists to be
a biological marker for sexual risk taking. The
2007 IBBS and earlier data indicate widespread
sexual risk taking in the commercial sex industry
and little evidence that progress is being made
in changing the situation. The prevalence of
Chlamydia, gonorrhea and active syphilis among
FSWs in Indonesia in 2007 are extremely high
- among the highest recorded among Asian
countries.
A number of factors appear to be responsible
for this, including low rates of condom use,
inadequate coverage of STI screening and
treatment, and ineffective diagnostic and
treatment regimes. While moderate levels of
coverage of FSWs with routine screening have
been achieved in many cities, coverage needs
to be higher and more consistent in order to
reduce STI prevalence. Beyond screening, the
data indicate that only about one-half of FSWs
seek professional medical help when faced with
signs and symptoms of STIs - the remainder selfmedicate, go to other types of service providers,
or take no action at all. This combined with
partial resistance to some first-line STI drugs and
incomplete compliance with treatment regimes
by some FSWs, have led to inadequate treatment.
The need for more aggressive and effective
treatment of syphilis is urgent.
With regard to diagnosis, it is well established
that the syndromic approach has low sensitivity
and specificity among women. However, there
is little evidence that the enhanced syndromic
approach that has been tried in a number of
clinics around Indonesia has been cost effective.
Given the high STI prevalence rates among
FSW more or less across Indonesia, periodic
presumptive treatment (PPT) of all FSW with
single¬ dose, directly observed treatment with
effective drugs should be considered for rapid
expansion.
79
Epidemiology & STI
Data from the 2007 IBBS provide insights into the
current status of the HIV/AIDS epidemic among female
sex workers (FSW), as well as data with which to
update trends in HIV-related biological and behavioral
and key recommendations concerning FSW include the
following:
Epidemiology & STI
Consistent condom use is low and strong
condom
promotion
strategies
with
comprehensive coverage of FSWs are needed.
Neither routine STI screening and treatment nor
PPT will be effective unless condom use rates
among FSWs can be increased. Unfortunately,
the 2007 IBBS data indicate that consistent
condom use with clients was quite low and has
not increased over the past five years. This is
due in part to inadequate levels of knowledge
of the protective benefits of condoms by FSWs.
However, FSWs also report that condoms are
not always available to them, most had not had
hands-on practice with condom in the past year (if
at all), and the frequent rate of condom breakage
suggests widespread improper application of
condoms. Because of the power imbalance in
FSW-client relationships, FSWs are also often not
empowered to insist upon using condoms even
when they are available and they know how to
use them.
A large-scale, nationwide condom education,
destigmatization and promotion program
targeted to FSWs, clients and stakeholders in
the commercial sex industry is urgently needed.
Interventions should put emphasis not only on
FSWs’ ability to negotiate condom use, but also
on skills to use condoms, as well as innovative
interventions to clients and stakeholders
involved in the sex industry. This effort should
be adapted to local context and bought into
by local stakeholders in both planning and
implementation to ensure commitment of all
actors to effective HIV/AIDS prevention. There
have been local success stories in containing STIs
and HIV among FSWs, and these should be used as
models for other communities around Indonesia
to stem the HIV epidemic among FSWs.
Surveillance Highlight: High Risk Men
For HIV surveillance purposes, males in occupational
groups known or suspected to be frequent clients
of female sex workers (FSW) are considered to
be High Risk Men (HRM). Such men represent an
important “bridge” population between FSW, one
of the population sub-groups in Indonesia in which
the HIV/AIDS epidemic is currently concentrated,
and the general population. Surveillance of such
bridge groups serves to provide early warning of
the potential spread of HIV/AIDS into the general
80
population. In the 2007 IBBS, men were selected
from four occupational categories: truck drivers
(in Deli Serdang and Batang), seafarers (in Batam,
Medan, Semarang, and Surabaya), dock workers (in
Jakarta, Merauke, and Sorong) and moto-taxi drivers
(in Medan, Banyuwangi, and Jayapura). This summary
presents key findings of the IBBS 2007 for these
groups of men. Data are presented by occupational
group separately for Papua and non-Papua provinces
to account for the difference between those areas in
level of HIV epidemic in the general population.
Key Finding 1: HIV become detectable among high
risk men outside of Papua.
HIV has been undetectable among HRM in prior
surveillance efforts in Indonesia. The 2007 IBBS did
not detect any cases of HIV infection among mototaxi drivers outside of Papua. However, 0.2% of truck
drivers and 0.5% of seafarers were infected with HIV.
In Papua, the prevalence of HIV was much higher,
with 1% of the moto-taxi drivers and 3% of the
dockworkers being infected with HIV.
Key Finding 2: The prevalence of Chlamydia has
reached modest levels among HRM, especially in
Papua, while the prevalence of syphilis is relatively
high in all occupational groups in all geographic
locations. This justifies intensification of STI
control efforts among HRM. However, few HRM are
at present using public sector health services for
treatment of STI.
Chlamydia is more frequent than gonorrhea among
high risk men. The prevalence of both Chlamydia and
gonorrhea is extremely high in Papua, which would
justify general population screening and treatment
interventions in Papua. The prevalence of syphilis is
alarmingly high in all groups and geographic areas.
Except for dock workers in Papua, among whom 63%
had their last STI treated at a public health facility,
public health services were rarely used by HRM when
they had symptoms of STI in the last year - less than
25% in all occupational groups (see data table). The
majority (52% to 71%, depending upon occupational
group and province) preferred to either self-treat or
abstain from treatment
Epidemiology & STI
Although the testing algorithm used in the 2007
IBBS does not allow differentiation between current
syphilis infection and past infections, such high
prevalence in a non-sex worker sub populations
justifies the intensification of screening for and
treatment of syphilis on a wider basis than is currently
being undertaken.
partner in the past year. In Papua, the proportion of
HRM who had either sex with a FSW or with a casual
partner in the past year was more than double of that
reported in provinces outside of Papua.
Key Finding 4: Consistent condom use by HRM is low
with both FSW and casual partners, but is higher in
Papua than in other provinces. Most HRM did not
know that condoms can protect them against HIV
transmission.
Key Finding 3: Truck drivers and seafarers were the
most exposed to risk of HIV and STI transmission from
sexual contact with FSW. Within similar occupational
groups, those from Papua had greater exposure to
FSW than those from other provinces. Sex with casual partners is also more common in Papua.
The highest proportions of HRM reporting having
had sex with FSW in the past year are found among
truck drivers (60%) and seafarers (46%) outside of
Papua. Sex with FSW was also quite common among
both moto-taxi drivers (34%) and dock workers (43%)
in Papua. Sex with casual partners in the past year
was more prevalent in Papua than in other provinces:
30% of moto-taxi drivers and 25% of dock workers
from Papua reported having had sex with a casual
Most HRM do not use condoms consistently with
either FSW or causal partners. Consistent use of
condom with FSW in the past 3 months ranged
from 7% to 21% among the different occupational
groups outside of Papua and from 37% to 46% in
Papua. Truck drivers, the occupational group with the
highest frequency of sex with FSW, are also the least
likely to use condoms. When taking into account men
reporting not having had sex during the last year, the
various type of partners they had and their condom
use behaviors, 37% of the truck drivers and 31% of
the seafarers had unprotected sex with a casual
partner or a FSW in the past year, which makes them a
high priority target for future interventions (see data
table). By comparison, only 8% of the dock workers
and 9% of the moto-taxi drivers outside Papua had
unprotected sex with a casual partner or a FSW in the
past year, but those from Papua were more likely to
engage in unprotected sex (29% among dock workers
and 25% among moto-taxi drivers). Knowledge that
condoms can protect against sexual transmission
of HIV was low, ranging from 36% to 55% (see data
table), which partially accounts for their relatively
infrequent use.
81
Epidemiology & STI
, been tested for HIV.
Key Finding 5: Few HRM have
In Papua, 5% of moto-taxi drivers and 7% of dock
workers had received the results of an HIV test in
the past year (see data table). Outside Papua, only
1% of truck drivers and 0% of moto-taxi drivers
had acknowledged their HIV sero-status in the past
year. While 4% of the seafarers outside Papua had
received their HIV test results in the past year, most
did it to obtain a certificate for employment (data not
presented).
Key Finding 6: Few HRM inject drugs. However some
truck drivers and seafarers use methamphetamines,
which may increase their risky sexual behaviors.
Very few HRM reported having had injected drug
in the past year (see data table). However, 7% of
both truck drivers and seafarers reported having
used methamphetamines in the past three months,
while in Papua, 8% of moto-taxi drivers had used
methamphetamines in the past three months. The
available scientific evidence indicates that persons
using methamphetamines tend to engage in risky
sexual behaviors more frequently than non users.
Data from the 2007 /BBS among most at risk groups
status of the HIV/AIDS epidemic among high risk men
(HRM), as well as data with which to update trends
in HIV¬ related biological and behavioral indicators
over time. These data thus contribute to the growing,
but still limited, evidence base for decision making
concerning HIV/AIDS in Indonesia. Conclusions and
key recommendations concerning HRM include the
following:
Outside Papua, although the prevalence of
82
HIV remains low, HIV is now detectable among
certain occupational groups of HRM. These
men get infected via contact with FSW and
require focused prevention interventions.
High-risk men (HRM) serve as a potential bridge
between FSW and the general population. They
get infected with HIV through sexual contact
with FSW and may transmit the infection to their
wife or girlfriends. The frequency of exposure
to unprotected sex with a non-regular partner
remains low in groups like moto-taxi drivers and
dock workers. However, most truck drivers and
seafarers report frequent sex with FSW and casual
partners, and the vast majority of such encounters
continue to be unprotected. Knowledge of the
protective effects of condoms is low, and the
sexual risk behavior may be increased by the use
of methamphetamines among some HRM.
Programs specifically designed for HRM truck
drivers and seafarers in particular are needed.
These should aim at establishing peer networks
and intervening in workplaces in order to
maximize coverage. Key components should
include access to accurate information on HIV
and STI, behavior change communications/
interventions, condom promotion, secure access
to condoms, access to effective treatment of
STIs, information on risk associated with drug
abuse, and promotion of voluntary counseling
and testing services. Priority attention should be
given to providing information to and intensively
supporting consistent condom use with FSW
and casual partners. Programs should involve the
companies that employ these men. The use of
various media, including mass media, is needed
to achieve sufficient program coverage of H RM.
Epidemiology & STI
In Papua, HIV and STI prevalence is already
high. Sex with non-regular partners is more
frequent than among men in comparable
occupations in other parts of Indonesia,
particularly with casual partners. This
contributes to the spread of HIV to the general
population. Although condom use is higher
than in other parts of Indonesia, it remains
insufficient to significantly disrupt disease
transmission at the population level and is far
too low with casual partners.
The data collected from the occupational groups
surveyed in Papua suggest that many urban
men with salaries may be at risk in Papua. The
HRM covered in the 2007 IBBS report a relatively
high frequency of sex with both FSW and casual
partners. Sex with casual partners is likely to
contribute to the expansion of the epidemic
in the general population. In the majority of
the cases, sex with casual partners remains
unprotected. The prevalence of STI is relatively
high, which accelerates dissemination of the HIV
epidemic. Papuan men have weak knowledge
of the protective effects of condoms on sexual
transmission of HIV, inconsistently use medical
services for treatment of STI, and only a small
proportion of HRM have sought to learn their HIV
sero-status.
In Papua, although HIV prevention programs
need to be directed to the general population,
the 2007 IBBS data suggest that men in the types
of occupational groups covered in the survey
should be specially targeted in view of their risk
behaviors. These programs should aim at raising
awareness on risks associated with sex with FSW
and casual partners, destigmatizing condoms
and increasing their use with both FSW and
casual partners, and increasing uptake of medical
services for STI treatment and HIV testing. Key
components should include access to accurate
information on HIV and STI, behavior change
communications, condom promotion, partner
reduction promotion, secure access to condoms,
and access to effective treatment of STIs and
voluntary counseling and testing services.
Access to these men should be maximized by
using multiple channels to deliver information,
including mass media, peer education, and
workplace programs. Control of STI among HRM
is a high priority in Papua.
83
Epidemiology & STI
The prevalence of syphilis is extremely high
among all groups of HRM, both in Papua and
outside Papua.
Syphilis is a potentially lethal, ulcerative STI that
increases the probability of HIV transmission.
However, it is easy to diagnose and can be treated
by a single shot of an inexpensive antibiotic. The
test used among HRM in the IBBS did not permit
differentiation of current from past syphilis.
However, because of the low uptake of medical
services reported by HRM in case of STI and the
apparent resolution of symptoms in the absence
of treatment, it is likely that some if not many of
the syphilis cases did not use medical services
and were actually active syphilis cases at the
time of the survey, thus elevating the risk of HIV
transmission.
In light of this, high priority needs to be given
to more aggressive syphilis screening and
treatment by public health authorities. In
addition, campaigns educating the population to
syphilis risk and symptoms, as well as promoting
utilization of screening and treatment services,
should be undertaken to generate demand. The
high prevalence of syphilis among HRM across
Indonesia, but especially in Papua, makes this a
priority area for intervention.
IBBS results from Jakarta, Bandung and Surabaya
indicate high prevalence of HIV and other STIs
among Waria. HIV prevalence ranged from 14% in
Bandung to 34% in Jakarta, prevalence of either
rectal gonorrhea or Chlamydia from 42% in Jakarta
to 55% in Bandung, and syphilis prevalence from
25% (Jakarta and Bandung) to 30% in Surabaya
(Figure 1).The prevalence of syphilis is noteworthy,
being among the highest recorded in Asian countries
in recent years. Prevalence of urethral STIs, however,
was low (0-2%).
Surveillance data for Waria going back to 1995 are
available for DKI Jakarta (see Figure 2). These data
provide a longer-term view of the evolution of the HIV/
AIDS epidemic among Waria in Jakarta, which along
with Surabaya has the largest number of resident
Waria among Indonesian cities. Although the data
should be interpreted cautiously due to differences
in sampling methodology in the different rounds of
surveillance data collection, the upward trend in HIV
prevalence among Waria is unmistakable.
Key Finding 2: The large majority of Waria sell sex to
male customers. Many Waria also have regular, non-
Surveillance Highlight: Waria
In Indonesia, men who have assumed a female
identity (transgender or transvestite) are referred to
as Waria. Prior surveillance data indicate that Waria
tend to engage in risky sexual behaviors, and have
high HIV prevalence. This summary presents key
findings of the IBBS 2007 for Waria from five (5) cities
(Jakarta, Bandung, Semarang, Surabaya and Malang).
Behavioral data were gathered in all five cities, while
biological data were gathered in three cities (Jakarta,
Bandung and Surabaya). Official estimates indicate
that there were between 20,960 and 35,300 Waria in
Indonesia in 2006.
Key Finding 1: HIV and sexually transmitted infection
(STI) prevalence rates among Waria were extremely
high in the three cities in which biological data were
collected. The HIV sub-epidemic among Waria appears to be expanding.
84
commercial male sexual partners.
Over 80% of Waria in four of the five cities reported
having sold sex to male customers in the past year
(Figure 3). The median duration of selling sex ranged
between 9 and 13 years (see data table). The median
number of clients in the last week ranged from 1 to 4
in the five cities. Typical places for meeting customers
included along specific streets (53%), in parks (16%),
and beauty parlors (13%) (data not shown). More than
90% of Waria reported having both anal and oral sex
with clients during the last year. In addition to clients,
and 40-50% of Waria also reported having regular
male partners that they referred to as “husband”. Few
Waria reported female partners in the prior year.
Waria are knowledgeable about actions that could
reduce the risk of HIV transmission. Over 90% of
Waria in four of the five cities knew that condoms
protected against HIV infection, 80% or more knew
that reducing their number of sexual partners
would reduce their risk of infection, and 63%-79%
knew that anal sex exposed them to elevated risk
of HIV infection. The exception was Jakarta, where
knowledge of prevention measures was much lower.
Key Finding 3: Consistent condom use during anal sex
among Waria remains insufficient.
The 2007 IBBS data reveal low-to-moderate rates of
consistent condom use during anal sex during the
last month. Consistent condom use in receptive anal
sex with clients ranged from 13% in Jakarta to 48%
in Bandung. Consistency of condom use in insertive
and receptive anal sex were comparable in three of
the cities, but in Semarang and Malang condom use
in insertive anal sex was significantly less frequent
than in receptive sex, perhaps indicating recognition
of the higher risk of HIV infection associated with
However, misperceptions about HIV/AIDS were
widespread in all five cities, resulting in low overall
knowledge of HIV/AIDS. Waria reported condom
breakage rates although Waria tended to be aware
of the protection offered by condoms, they did not
necessarily know how to use them properly.
Key Finding 5: Substantial proportions of Waria had
recently received STI management services and HIV
counseling and testing.
unprotected receptive anal sex. Consistency of
condom use with casual partners was slightly lower
than with clients in all five cities. The proportion of
Waria that were carrying a condom and lubricant with
them at the time of the IBBS survey interview ranged
between 41% and 51% in four of the five cities, but
was only 20% in Semarang (see data table)
Coverage of STI services among Waria in the three
months prior to IBBS data collection exceeded 50%
in four of the five cities, reaching as high as 89% in
Bandung and 88% in Malang, and fell just below
50% in Semarang (Figure 6). Except in Surabaya,
roughly comparable proportions of Waria had
received HIV counseling and testing services as had
been screened for STIs in the previous three months,
which likely reflects the impact of co-locating STI
management and VCT services in these cities at
85
Epidemiology & STI
Key Finding 4: Knowledge of preventive measures
against transmission of HIV and STI was moderate to
high in four of the five cities, but knowledge of HIV/
STIs tended to be superficial.
Epidemiology & STI
strategically chosen Puskesmas. This finding might
also reflect the increasing adoption of “opt-out”
strategies wherein Waria who present at clinics for
STI screening automatically receive HIV pre¬test
counseling and an opportunity to be tested for
HIV. The reasons for the significant gap in coverage
between of STI and VCT services among Waria in
Surabaya should be explored, as such a gap indicates
numerous missed opportunities for Waria to learn
their current HIV status. More than 90% of Waria
who had ever been tested for HIV had been tested
during the last year, perhaps reflecting expansion
of service availability, increasing acceptance of VCT
among Waria, or both.
months ranged between 37% in Semarang and
72% in Bandung. Drug use, however, was much less
common, with the proportion using non-injecting
drugs in the past year ranging between 3% and 17%
in Malang and Jakarta, respectively. The proportion
of Waria injecting drugs in the past year was quite
low - 2% or under in four of the five cities.
Key Finding 6: Alcohol use among Waria is quite high,
but use of drugs is moderate to low.
status of the HIV/AIDS epidemic among Waria, as well
as data with which to update trends in HIV-related
biological and behavioral indicators overtime. These
data thus contribute to the growing, but still limited,
evidence base for decision making concerning HIV/AIDS
in Indonesia. Conclusions and key recommendations
concerning Waria include the following:
Alcohol use among the Waria in all five cities was
moderately high (see data table).The proportion
of Waria who consumed alcohol in the past three
The high HIV and STI prevalence rates among
Waria demands urgent action to expand
program coverage, increase condom and
86
Epidemiology & STI
lubricant use rates, and increase their regular
use of STI management services.
High STI prevalence and rising HIV prevalence
among Waria indicate that existing programs
have not yet resulted in adoption of risk
reduction behaviors on a sufficient scale to slow
the sub-epidemic among Waria. As the primary
clients of Waria tend to be young men, who
constitute a potential “bridge” to the general
population, Waria have the potential to have
a much larger impact the HIV/AIDS epidemic
in Indonesia than their numbers alone would
suggest. Programs need to both expand their
coverage and their effectiveness in influencing
risk-taking and health-seeking behaviors
among Waria. Key program components
should include access to accurate information,
behavior change communications, condom and
lubricant promotion, secure access to condoms
and lubricants, access to effective treatment of
STIs, access to voluntary counseling and testing,
and access to care, treatment and support. In
view of generally low education levels among
Waria (see data table), providing information
in simple, easy-to-understand ways is crucial.
Because of their influence program efforts are
likely to be most effective if they involve/work
through “mammies” (that is, mother figures
who are leaders of Waria communities) and/or
through Waria organizations.
The high prevalence of rectal STIs among
Waria should be addressed with a combination
of Periodic Presumptive Treatment (PPT) and
more regular STI screening of Waria. Syphilis
merits special attention.
Periodic presumptive STI treatment (PPT) has
been shown in Indonesia and elsewhere to result
in at least short-term reductions in STI prevalence
among female sex workers. PPT should be
extended to Waria, among whom routine STI
screening and treatment heretofore has not been
successful in reducing STI prevalence even with
relatively high coverage, as well as their regular
partners. Special attention should be given to the
diagnosis and treatment of syphilis among Waria
given the danger of syphilis as a risk co-factor for
HIV transmission.
Increasing consistent condom use among
Waria should be the highest priority.
Neither routine STI screening and treatment
nor PPT will be effective in maintaining low STI
prevalence among Waria unless condom use
rates are increased. Unfortunately, the 2007
IBBS data indicate that the proportion of Waria
who consistently used condoms with clients
and regular partners failed to reach 50% in any
of the five cities for which data was available,
and in Jakarta failed to reach 20%. In the case
of Waria, this is NOT due to inadequate levels of
knowledge of the protective benefits of condoms.
The data suggest that reliable access to condoms
87
Epidemiology & STI
is an issue, and most Waria had not had handson practice in using condoms in the past year (if
at all). The frequent (reported) rate of condom
breakage suggests widespread improper
application of condoms. Operations research
should be undertaken to better understand
the barriers to increased and correct condom
use among Waria to guide the modification of
interventions to overcome these barriers, and
programs should focus on educating Waria on
proper condom use.
Attention needs to be focused on adopting
safe sex practices with noncommercial
partners as well as customers.
The 2007 IBBS data indicate that many Waria have
regular male partners (“husbands”) in addition
to multiple commercial sex clients, and that
consistent condom use appears to be even lower
with such partners than with commercial clients.
Special initiatives are needed to encourage
condom use and to reach regular partners of
Waria with accurate information on HIV/AIDS and
risk reduction strategies. As with IDU, partners of
Waria should be encouraged for STI to be tested
for STIs and HIV as a matter of high priority.
PPT for regular partners of Waria might also be
considered.
Prevention efforts for Waria should focus
greater attention on those already infected.
Global research evidence indicates that behavior
change interventions tend to be more effective
among persons who know their HIV status,
particularly among those who are HIV positive.
In view of the relatively high HIV prevalence
rates among Waria in Indonesia, significant
gains in prevention cost-effectiveness and
impact might be realized by assigning highest
priority in prevention initiatives to motivating
and enabling Waria who are already infected to
take steps to avoid infecting others, both clients
and regular partners or “husbands” However, it
will be necessary to improve the quality of HIV
counseling and mobilize communities of Waria
to take positive action in this regard in order for
this approach to be effective.
Clinic visits by Waria should be used to greater
advantage to promote increased condom use
and other risk reduction strategies.
88
In the cities in which data on Waria were
gathered for the 2007 IBBS, Waria appear to
be willing and able to use public health clinics
(Puskesmas) to access STI management services
and HIV counseling and testing. Visits by Waria
to such facilities provide opportunities for
clinic staff to promote increased condom use
and other protective behaviors and should be
taken maximum advantage of. Guidelines and
educational and behavior change materials for
use by clinic staff to promote HIV prevention
should be developed and widely disseminated
as quickly as possible.
Prevention efforts among Waria should also
focus on alcohol abuse.
Excessive alcohol consumption has been
established as a risk factor for sexual risk taking
and HIV transmission on more or less a global
basis. As little is known about the role that
alcohol abuse plays in sexual risk taking among
Waria in Indonesia, formative research should
be undertaken to guide potential interventions
designed to reduce the impact of alcohol on HIV
transmission among Waria and their clients and
partners.
Surveillance Highlight: Men Who Have
Sex with Men
Recent regional analyses indicate that unprotected
sex among men who have sex with men (MSM) is
making an important and at least in some cases
growing contribution to HIV/AIDS epidemics in many
Asian countries. The 2007 IBBS collected behavioral
data from MSM in six cities - Medan, Batam, Jakarta,
Bandung, Surabaya and Malang, and biological data
in three cities - Jakarta, Bandung and Surabaya.
This summary presents the key findings from the
IBBS with regard to MSM. It is estimated that there
were between 384,320 and 1,149,270 MSM (average
766,800) in Indonesia in 2006.
Key Finding 1: STI rates were very high among MSM
in Jakarta, Bandung and Surabaya, especially among
those engaging in commercial sex.
Between 29% and 34% of MSM in the three cities in
which biological data were collected were infected
with one or more rectal STIs, with Chlamydia being
slightly more prevalent than gonorrhea (see Figure 1
Around 60% of MSM reported using a condom
during last sex with a male partner. Condom use at
last sex with a male partner did not vary significantly
depending upon whether the transaction was casual
or commercial. Condom use at last sex with females
was less frequent, falling to 32% in encounters with
casual female partners. Consistent condom use in the
last month was, however, considerably lower - about
30% with male partners in both non-commercial
and commercial transactions. With female partners,
Key Finding 2: MSM tend to have multiple sex partners, both male and female, and significant numbers
also buy and sell sex.
MSM reported having had sex with a number of
different types of partners in the last year, female as
well as male. Almost 87% of MSM reported having
casual sex (without giving or receiving payment)
with a male partner and 40% with a female partner in
the year prior to the IBBS survey (Figure 2). Only 16%
reported having had sex with a Waria or transgender
in the prior year. The median number of male partners
per MSM in the month prior to the IBBS survey was 4,
but reached as high as 10 in Jakarta and 7 in Medan
(see data table). The median number of female
partners per MSM in the prior month was 1. Buying
and selling sex with male partners was common 20% reported buying sex from and 47% selling sex
to a male partner in the past year. The corresponding
figures for buying and selling sex with female
partners were 10% and 14%, respectively. One-third
of MSM also reported having a regular male partner
and 16% a regular female partner, and 22% reported
that their regular partners also had other partners.
These complex sexual networks increase the risk of
transmission among MSM and their sexual partners.
consistent condom use ranged from 11 % with casual
partners to 18% when selling sex. Use of water-based
lubricants during last anal sex ranged from 12% in
Batam to 22% in Malang (see data table).
Between 53% of MSM (in Batam) and 83% (in
Jakarta) had receptive anal sex in the previous
month, while the proportion of MSM reporting
having insertive anal sex in the prior month ranged
from a low of 65% in Bandung to a high of 92% in
Medan (see data table). Consistent condom use in
anal sex during the prior month with all partners
exceeded 20% in only one city - Malang (23% in
insertive and 26% in receptive anal sex), and did
not vary significantly depending upon whether
anal sex was receptive or insertive.
Key Finding 3: Consistent condom use remains low.
89
Epidemiology & STI
and data table). The high prevalence of rectal STIs is
an indication of high prevalence of unprotected anal
sex. Prevalence of urethral STIs was lower, ranging
between 5-8% in the three cities (data not shown).
HIV prevalence rates among MSM ranged from a high
of 8.1 % in Jakarta to a low of 2% in Bandung. STI and
HIV prevalence rates were higher among MSM who
had bought and sold sex (data not shown).
Epidemiology & STI
AIDS, and 17% had called a hotline service.
Key Finding 4: Knowledge of preventive measures
against sexual transmission of HIV and other STI was
moderate to high in the six cities, but overall knowledge was lower.
Key Finding 6: Moderate proportions of MSM had recently used STI management services and received
HIV counseling and testing.
High proportions of MSM (over80%) in all six cities
knew that condoms could protect them against
HIV and 5TI transmission, and between 63% and
87% knew that their risk of HIV and STI transmission
could be lowered by reducing their number of sexual
partners. However, knowledge of other aspects HIV
and STIs transmission and prevention was much lower,
particularly in Bandung, Malang, and Surabaya, with
a number of myths and misperceptions continuing
to persist. Nevertheless, the level of knowledge of
prevention measures among MSM was sufficiently
high to significantly impact the sub-epidemic among
MSM if this knowledge were to be put into practice.
Utilization of STI diagnostic and treatment services
remains insufficient in view of STI prevalence among
MSM. The proportion of MSM who had visited a STI
clinic in the three months prior to the IBBS ranged
between 18% and 30% in five cities, but reached 68%
in Malang. Fifty-seven percent of MSM in Malang
had ever been tested for HIV versus between 23%
and 41 % in the other five cities. Most MSM who had
ever been tested for HIV had been tested in the year
prior to the 2007 IBBS, likely reflecting improvements
in availability of HIV counseling and testing services,
increasing acceptance of the need for and/or the utility
of HIV counseling and testing among MSM, or both.
Key Finding 5: MSM receive information about HIV/
AIDS from a variety of sources.
MSM receive information on HIV/AIDS from multiple
sources, the most common being through printed
materials (that is, brochures, pamphlets - 73% in
the past year), contacts with NGO outreach workers
(54%), contact with health workers (49%), and
“edutainment” events (27%). Smaller proportions
had received information via internet or hotlines.
This likely reflects the limited reach of these channels
of communication targeted to MSM. However, where
electronic and telephonic sources of information were
more readily available, substantial proportions of
MSM report having obtained information from such
sources. For example, in Malang 28% of MSM received
information on HIV/AIDS through internet chat rooms
or messenger services in the last three months, 24%
used internet websites to seek information on HIV/
90
While these results are encouraging, the IBBS
data also indicate that MSM tend not to take full
advantage of available services. More than 70% of
MSM in the six cities reported that they had been
offered an HIV test, but only 38% had actually been
tested (data not shown). On a more positive note,
almost all of those who had been tested reported
that they had received their test result.
Key Finding 7: Although overall drug use affects only
a small proportion of MSM, recent use of metham-
phetamines and similar drugs was reported by sizeable proportions of MSM in some cities. However, few
MSM inject drugs.
Injecting drug use and multiple sexual partners is a
particularly dangerous combination, with potential
to rapidly accelerate the progression of HIV/AIDS
status of the HIV/AIDS epidemic among men who have
sex with men (MSM), as well as data with which to
update trends in HIV-related biological and behavioral
and key recommendations concerning MSM include
the following:
91
Epidemiology & STI
epidemic in the ranks of MSM. Fortunately, few
MSM reported injecting drugs in the past year (see
data table). However, 31% of MSM in Jakarta and
25% in Batam reported using drugs such as ecstasy,
methamphetamines and ice in the past 3 months.
Use of such drugs can impair men’s judgment and
ability to use condoms regularly and correctly, and
thus merits the attention in future HIV prevention
efforts directed to MSM.
Epidemiology & STI
High STI prevalence among MSM indicates an
urgent need for increased condom use and an
expansion of HIV-STI-related services offered
in accessible and “friendly” settings.
The high STI prevalence observed among MSM in
the three cities from which biological data were
gathered and reported inconsistency in condom
use provide clear evidence of substantial levels
of sexual risk taking among MSM in Indonesian
cities. Programs targeting MSM need to be scaled
up in cities with sizeable populations of MSM.
Such programs should include not just education,
behavior change communications and improved
access to condoms and lubricants, but a full
range of HIV-related services made accessible
and “friendly” to MSM; that is, in non-threatening
settings where MSM feel comfortable coming for
services.
Because many MSM in Indonesia remain “hidden”
and thus hard to reach, efforts to reach them
with information and services must go beyond
conventional “outreach” approaches involving
direct, face to-face contact at commercial sex
sites and other places where MSM gather.
Greater advantage should be taken of existing
networks of MSM to reach deeper into MSM
communities, perhaps through increased use
of telecommunications media (e.g., internet,
hotlines, etc). The IBSS data suggest that
internet, hotlines and other “electronic” means
of communication reach significant proportions
of MSM where they are available, and given the
relatively high educational status of MSM in
Indonesia would seem a promising approach to
expanding program reach.
Targeting only MSM who buy and sell sex will
have limited impact.
92
In large Indonesian cities, it is easy to find venues
where MSM buy and sell sex. While programs
need to reach buyers and sellers at such sites with
information and improved access to condoms,
lubricants, and diagnostic and treatment
services, the fact that such men had HIV and STI
prevalence rates that were only slightly higher
(2-3 percentage points on average) than MSM
that do not buy and sell sex confirms that risktaking behaviors are rather widespread among
MSM. To contain HIV/AIDS among MSM, there
is no feasible programmatic alternative but to
reach all MSM with information and services.
Consistent condom use with all partners is
essential to containing the HIV epidemic
among MSM.
The IBBS data point to complex sexual networks
among MSM involving multiple partners
of different types of both genders. The fact
that condom use with female partners was
significantly lower than that reported with
male partners suggests that there may be a
perception among MSM of differential risk of
STI and HIV transmission with different types
of partners. To reduce incidence of HIV and STI
infections, interventions need to emphasize the
importance of consistent condom use with all
sexual partners.
The uptake of HIV counseling and testing
remains limited among MSM and needs to be
greatly increased.
More than 70% of MSM in the five cities covered
by the 2007 IBBS reported having been offered
HIV counseling and testing. This would seem
to suggest that lack of physical access to HIV
C&T services is no longer the major constraint
against increased service uptake. However, only
about one-half of the MSM who have been
offered HIV counseling and testing had actually
networks of MSM so that this information can
be used to more effectively reach MSM with
programs aimed at changing risk behaviors and
addressing psycho-social barriers to utilization of
HIV-related services.
The relatively high prevalence of use of
methamphetamines and similar drugs in
some cities merits attention as part of HIV
prevention efforts for MSM.
There is growing concern globally over the
role that use of drugs such as ecstasy and
methamphetamines plays in reducing sexual
inhibitions among MSM and adversely affecting
adoption of safer sexual practices. Although
the use of such drugs is not yet widespread
among MSM in Indonesia, their use has reached
significant levels in at least two Indonesian cities
(Jakarta and Batam). This should serve as a “wakeup call” for HIV prevention efforts to address the
issue before it becomes a larger problem.
Further research is needed to both more
accurately establish the size of MSM
populations in cities throughout Indonesia
and to better understand sexual networking
among MSM.
Although national and provincial estimates have
been made of the number of MSM in Indonesia,
further work is needed to more accurately
determine population size and geographic
distribution of MSM across Indonesia. Also in
need of further study are the social and sexual
93
Epidemiology & STI
gone on to be tested. Although only 8% of the
MSM interviewed in the 2007 IBBS reported
experiencing discriminatory treatment, it may be
that fear of stigma and discrimination continues
to act as a constraint to fuller service utilization.
Qualitative research is needed to determine
why more MSM are not taking advantage of
HIV counseling and testing and other available
services, and the results of such research fed back
into programs so that corrective actions can be
taken to increase program coverage.
Epidemiology & STI
Social & Behavioral
95
Social & Behavioral
AIDS Knowledge, Condom Beliefs and Sexual
Behaviour among Male Sex Workers and Male
Tourist Clients in Bali, Indonesia
Kathleen Ford1
Dewa Nyoman Wirawan2
Peter Fajans1
1
Department of Population Planning and International Health, School of
Public Health, University of Michigan, Ann Arbor, USA.
2
School of Medicine, Udayana University, Bali, Indonesia.
Health Transit Rev. 1993 Oct; 3(2): 191-204
Health Transition Centre, National Centre for Epidemiology and Population Health, Australian National University
97
Abstract
The objective of this paper is to describe the AIDS knowledge and risk behaviours of male sex workers who serve predominantly male clients in
Bali, Indonesia, to discuss implications for the spread of the disease, and to discuss appropriate interventions for these groups. Data are drawn
from a qualitative study of the workers and clients consisting of interviews with many open-ended questions. The results of the study are viewed
in terms of the AIDS Risk Reduction Model (ARRM). The data indicate that there is a very active community of male sex workers and male clients in
Bali that is at risk of AIDS infection. Multiple sexual partners, unprotected anal intercourse, and frequent experience with STDs put both workers
and clients at risk. Workers had limited knowledge of AIDS and STDs, although clients were mainly well informed. Both groups were characterized
by frequent mobility. High levels of alcohol use by clients were reported before and during sexual encounters and may be a factor in increasing
risky sexual behaviours. Interventions for these groups should include improving knowledge of workers, improving STD treatment for both
clients and workers, skills training for sex workers, and increasing availability of good quality condoms and lubricants.
Introduction and background
Transmission of HIV through sexual contact has been
the most frequent means of the spread of the disease.
Because of the link between multiple partners and
increased risk of AIDS established in the homosexual
population in the US, there is much concern about
the role that commercial sex workers may play in the
spread of HIV infection.
particularly with clients. High rates of condom use
(85%) were found for anal intercourse, although many
encounters involved only other sexual activities. Workers
were safest in sex with male customers, less safe with
other male partners, and least safe with female partners.
The two most comprehensive studies were conducted
in the United States. In a study of fifty 14 to 27-yearold male prostitutes in New York City, Pleak and
Meyer-Bahlberg (1990) found that male prostitutes
had considerable knowledge about AIDS and this
knowledge was related to their behaviour.
Studies of male sex workers have also been conducted
in San Francisco. Data from a first study (Estep et al.
1991) showed that among hustlers, men who recruit
clients face to face (N=180), and callmen, more
educated men who operate from a book of clients,
masseurs, models, and escorts (N=180), general
knowledge of AIDS, specific information regarding
safe sex and AIDS, and number of customers serviced
were significantly related to the level of safe or
unsafe sexual behaviours (Estep etal. 1991). A larger
study that focused on condom use has recently
been completed. Five hundred and fifty callmen
and hustlers were interviewed during 1991 (Waldorf
and Lauderback 1991). Condom use was high for
workers in this study: nearly three quarters of the
workers had used condoms in the last week. Hustlers
reported considerably less frequent condom use for
anal intercourse than call-men and condom use was
less frequent for both groups with intimates than with
customers. Condoms were also much more likely to be
used for anal sex than for oral sex.
They often avoided anal intercourse and frequently
used condoms if they did engage in anal intercourse,
The remaining studies most relevant to Indonesia
come from Thailand. A study was conducted in
Although the literature on female commercial sex
workers has become fairly large, there are not many
published reports on male workers who serve male
clients. They include studies conducted in the United
States (Fowler 1989; Pleak and Meyer-Bahlberg
1990; Estep, Waldorf and Marotta 1991; Waldorf and
Lauderback 1991), in Europe (Tirelli et al. 1988; van de
Hoek et al. 1988; Robinson, Davies and Beveridge 1989;
Morgan Thomas 1990) and in Thailand (Muangman et
al. 1988; Sittitrai 1988, Sittitrai et al. 1989).*
*This project is a collaborative effort of the School of Medicine of Udayana University in Bali, Indonesia and the School of Public Health of the
University of Michigan, Ann Arbor. Financial support for this study was provided by Family Health International with funds from the United
States Agency for International Development (AID). Many persons have assisted with the project in Bali including
99
Social & Behavioral
AIDS Knowledge, Condom Beliefs and Sexual
Behaviour among Male Sex Workers and
Male Tourist Clients in Bali, Indonesia
Social & Behavioral
1988 of male sex workers in three areas of Thailand:
Bangkok, Hat Yai, and Chiang Mai (Muangman et al.
1988). In these areas, workers meet clients through
gay bars, bath houses, and public locations.
Most workers were in their twenties and the mean
incomes were low for the urban areas. Most workers
had some formal schooling with the lowest levels
in Hat Yai. The educational levels were higher than
comparable samples of female sex workers. About
two thirds of each urban group could identify
behaviours that spread AIDS, although knowledge
was lowest in Hat Yai. Unfortunately, less than half of
each of the three groups thought that AIDS could be
spread by an asymptomatic carrier. The number of
partners per week was highest in Hat Yai (seven), with
four per week in Bangkok and three in Chiang Mai.
Less than 50 per cent engage in anal intercourse in
Chiang Mai compared to 72 per cent of the Bangkok
sample and 86 per cent of the Hat Yai sample. About
10 per cent of Bangkok workers reported that they
never use condoms as against 30 per cent of Chiang
Mai workers, and 82 per cent of Hat Yai workers.
Intravenous drug use was negligible among male sex
workers in this study.
A second study (Sittitrai 1988) consisting of three
focus group discussions in male bars in Bangkok,
found workers’knowledge to be accurate about sexual
transmission, but found a number of misconceptions
about casual transmission. The male workers in
these groups also had higher educational levels than
female workers in the same areas. One important
finding from the discussions was that the workers
often found themselves to be pressured by both
customers and establishment owners to engage in
unsafe sexual practices. Most male workers reported
that they engaged in anal intercourse without
protection. The low incidence of condom usage was
a result of negative prior experiences with condoms
including breakage, small size, customer refusal, or
discomfort. Inappropriate lubricants including body
lotion, oil, and saliva were also used.
A third study (Sittitrai et al. 1989) was conducted with
141 male bar workers from five bars in Bangkok. As
with the other studies, these men had a large number
of sexual contacts and more than half engaged in
insertive and receptive anal sex without condoms.
In the two-week period before the interview, all
100
workers had sex with male clients, 23 per cent with
female clients, 13 per cent with nonclient males, and
50 per cent with non-client females. Thus, the sexual
activities of these young men put them at risk for HIV
infection and the potential for spread of the disease
was high because they have sex with both male and
female clients and non-clients.
Study context
At the end of 1992, the currently documented number
of AIDS cases and HIV-infected persons in Indonesia
was remarkably low: 80 cases were documented.
The Indonesian Ministry of Health has conducted
serotesting with particular emphasis on high-risk
groups including female commercial sex workers,
transvestites and gay men and only a few HIVpositive individuals have been identified. Most of the
individuals diagnosed with AIDS or who have tested
positive were gay men, although a small number
of prostitutes of both sexes have been identified as
seropositive. However, given the estimated large
numbers of sex workers in Indonesia and their
suspected high rates of sexually transmitted diseases
(STDs), there is a great potential for the spread of HIV
infection.
Bali, one of 27 provinces of Indonesia, is an island with
a population of nearly three million people. The recent
‘explosion’ in tourism with its attendant construction
and service industries, coupled with outside
investment in garment, craft and fisheries production
has brought a level of economic development and
opportunity that serves as a magnet to both the rural
and urban poor of neighbouring provinces such as
East Java (population 52 million). Thus, considerable
circular migration to and from Bali occurs, consisting
of both business people and tourists from Indonesia
and beyond, as well as the poor searching for
employment.
The commercial sex industry exists throughout
Indonesia and can be found throughout the island
of Bali. In Bali, however, it is concentrated in the
provincial capital city of Denpasar and the nearby
tourist centres of Kuta, Sanur and Nusa Dua. Both
Sanur and Nusa Dua tend to cater to the moreaffluent
tourists staying in relatively expensive hotels. Kuta is
the largest tourist centre and it attracts a wide variety
of tourists who stay in accommodation ranging from
cheap ‘homestays’ to five-star hotels.
A transvestite group known traditionally as wadem,
but more recently as waria, are visible and officially
recognized in Indonesian cities. The waria tend to
work as entertainers, hairdressers and sex workers.
However, apart from this group, homosexuality is
generally not accepted in Indonesia and persons
who reveal that they are homosexual are subjected
to discrimination. They tend to be ridiculed in films
and in the media, and in general only successful
persons in the arts and entertainment industry are
open about their sexual orientation.
The objective of this paper is to use data from a
qualitative study to describe the AIDS knowledge
and risk behaviours of male sex workers who serve
predominantly male clients in Bali, Indonesia, to
discuss implications for the spread of the disease,
and to discuss appropriate interventions for these
groups. The results of the study will be viewed
through the framework of the AIDS Risk Reduction
Model (ARRM).
This study focuses on the population in Kuta which is
estimated to include about 50 male prostitutes who
serve both Indonesians and foreign clients. Several
methods are used to meet customers: approaching
potential customers in particular areas along the beach,
soliciting partners on the street, going to residences,
and meeting in bars, nightclubs and discotheques.
Sexual relations may take place along the beach in
the bushes or small shacks made from palm fronds,
in the clients’ hotel rooms, or in the rooms of cheap
hotels rented specifically for the purpose. Liaisons
are often brief, but many become extended with the
client providing room and board, clothes, jewellery,
presents, and travel rather than direct payment to the
worker. In general, this commercial sex is not organized
by outside parties and prostitutes do not have to share
their proceeds with a pimp.
The AIDS Risk Reduction Model (ARRM)
The ARRM is a three-stage model that characterizes
people’s efforts to change sexual behaviours related
to HIV transmission (Catania, Kegeles and Coates
1990). The model aims to understand why people
fail to advance over the change process, in order to
gear intervention programs to a specific stage of the
change process. The first stage of the model involves
labelling behaviours as high risk for contracting HIV
and implies knowledge of the disease and belief that
the individual is at risk of the disease. The second
stage is a decision-making stage: individuals must
evaluate the costs and benefits of changing their
behaviour and whether they are capable of carrying
out that change (self-efficacy).
The third stage is the enactment stage. This stage
often includes information-seeking behaviour and
requires communication skills with sexual partners.
The model is used here to identify the stage of
behaviour change of sex workers and clients in
order to discuss appropriate interventions for both
groups.
Methodology
Subjects
From May to July, 1991, a convenience sample of
20 male commercial sex workers (CSWs) and 19 of
their tourist clients were recruited at places where
CSWs work including beaches, street areas, bars, or
discotheques. Friendship networks of CSWs were also
used to recruit sex workers into the sample. Clients
were recruited for the study either by meeting them
at CSWs’ work sites or at bars or discotheques where
CSWs recruit clients.
Survey instruments
The interview consisted mainly of open-ended
questions and assessed: (1) knowledge of AIDS,
sexually transmitted diseases, and condoms, (2)
socioeconomic and demographic characteristics and
migration history, (3) sexual experience, including
experience as a sex worker and experience with
intimates and other unpaid partners, (4) attitudes
and beliefs about condoms, and (5) other health
practices. This open-ended free-response format
has been recommended to identify beliefs and
social norms most likely to influence behaviour
(Ajzen and Fishbein 1980) and to identify constructs
101
Social & Behavioral
Commercial sex is illegal throughout Indonesia and
the law is periodically enforced in Bali bymeans
of token arrests and deportations of female sex
workers to their homes in East Java. Male sex workers
have generally not been subjected to such arrests.
Although the number of female commercial sex
workers in Bali is estimated to be over 1,000 the total
number of male sex workers in Bali is estimated at
one to two hundred.
Social & Behavioral
Table 1
Demographic and socioeconomic characteristics of male sex workers, Bali, Indonesia, 1991 (N=20)
most likely to influence behaviour (Higgins and
King 1981; Bargh 1984). Responses were recorded
on interview schedules in the presence of the
respondents. Separate questionnaires with similar
content were used for the workers and clients.
Interviewing procedure
The interviewing staff consisted of two Balinese males
and one American male. The Balinese interviewers
were university graduates in anthropology who had
spent time with the male sex-worker community.
They conducted all of the interviews with CSWs in
the Indonesian language. The American interviewer
was a gay male who had been living in the study
area for two years. He conducted the tourist client
interviews in English. Two tourist clients completed
self-administered forms. Interviewer training
included knowledge of AIDS and STDs, techniques
for conducting and obtaining interviews, detailed
study of the questionnaire, and supervised field
practise in conducting interviews. Interviews were
held at locations throughout the resort area including
homes, beach areas, hotels, and restaurants.
Locations were chosen to insure privacy during the
interview. Respondents were willing to answer the
sensitive questions in the interview and no significant
problems were reported by the interviewers.
102
Male sex workers
Demographic characteristics:
The age of the male sex workers interviewed ranged
between 18 and 30 years with a mean age of 22.7
years (Table 1). None had ever been married. All had
attended school with the majority having attended
at least some high school and an additional 20 per
cent having at least some university or academylevel education. The workers were likely to come
from middle-class economic backgrounds.
A few had fathers who were farmers or small traders,
but 60 per cent had fathers who were either civil
servants or in business. About 30 per cent of the
workers were not originally from Bali and most had
arrived within the last two years. As in Thailand, both
the level of education and parents’ socioeconomic
status were considerably higher than those of female
sex workers in Bali (Wirawan, Ford and Fajans 1992).
The best measure of ethnicity in the study is religion.
The ethnic Balinese are Hindu, and only one worker
reported Hindu religion. Those of Muslim religion
(70%) are mainly Javanese, while those who report
Christian religion may be from many parts of
Indonesia.
The workers were characterized by considerable
In Bali, 40 per cent reported living with other male sex
workers, while 45 per cent reported living with other
friends. Workers reported spending much of their free
time with friends who were also CSWs. Nine respondents
reported having other regular employment in addition
to sex work. Of these, nearly half worked as hairdressers
in beauty salons. Eighty-five per cent reported that they
would like an alternative occupation such as work in the
tourist business, modelling, or anything as long as it is a
‘good’ type of work.
AIDS knowledge
During the interview, workers were asked a series of
open-ended questions about AIDS. All of theworkers
had heard about AIDS and the major sources of
information were other gay men (85%), television
(75%), newspapers and magazines (55%) and tourists
(40%). When asked who can get AIDS, the most
common responses were gay men (85%), prostitutes
(60%) and gigolos, male sex workers serving female
clients, (50%). Other answers were that one can get
AIDS by having sexual intercourse with tourists and
with frequent partners. Only 15 per cent specifically
mentioned anal sex.
Eighty per cent reported that it was possible to tell
by looking if a person had AIDS, indicating that they
do not recognize asymptomatic infection. Reports of
symptoms of AIDS infections were often inaccurate.
The majority of sex workers (55%) felt that they
were at risk of getting AIDS. The most common
reason given for risk was ‘frequent sex with tourists’
(73%). For those who did not consider themselves
at risk, the most common reasons were that they
use condoms (75%) or that their body washealthy
(50%). Seventy-five per cent reported that they had
done something to avoid getting AIDS, and the most
frequent responses were that they use condoms
(60%) and that they select ‘clean’ clients (40%).
Sexually transmitted diseases
Sex workers were asked a similar series of open-ended
questions concerning their knowledge of and perceived
risk of other sexually transmitted diseases (STDs). All
respondents reported knowing of at least one STD
with 90 per cent mentioning syphilis, 90 per cent AIDS,
and only 35 per cent mentioning gonorrhoea. Most
reported either other gay persons (80%) or newspapers
and magazines (80%) as their sources of information
concerning STDs while 35 per cent reported tourists
and 25 per cent mentioned television as sources of
information. Although most sex workers had heard
of one or more STDs, their knowledge of the specific
symptoms associated with these diseases and the
mechanisms of transmission were often inaccurate.
Nearly all (95%) considered gay men to be at risk
of getting an STD, while 70 per cent reported sex
workers, 40 per cent gigolos; 30 per cent mentioned
tourists, and 15 per cent reported clients of sex
workers to be at risk of getting an STD. A wide variety
of responses were mentioned when asked how
those at risk can get an STD. Thirty per cent reported
frequent sexual partners to place one at risk, 20 per
cent mentioned not taking care of oneself, 15 per
Sex workers by client, requests
103
Social & Behavioral
mobility within Indonesia as well as outside the
country. In the previous two years, half had resided
in Jakarta, 30 per cent in Surabaya, the capital city of
East Java, 20 per cent in West Java and 20 per cent
in Central Java. In addition, individuals had also
lived in Singapore, Malaysia, Switzerland, and the
Netherlands. Most report visits to their home village
for holidays (85%).
Social & Behavioral
cent not selecting partners, and 15 per cent having
sex with tourists. Anal intercourse (15%) or oral sex
(15%) were also mentioned as placing one at risk of
an STD. The majority of respondents (95%) considered
themselves to be at risk of catching an STD, with 50
per cent reporting their having numerous or frequent
partners as the reason, while 13 per cent reported
having sex with tourists as placing them at risk. These
sex workers considered both tourists (95%) and other
Indonesians (85%) as people likely to have STDs while
55 per cent specifically mentioned gay sex workers as
people who suffer from STDs. A variety of alternative
Range
approaches to prevention of STD were reported.
Forty-five per cent of the respondents stated that they
had used a condom to prevent transmission while 35
per cent mentioned careful selection of partners, ten
per cent took antibiotics after sex, ten per cent avoid
anal sex and ten per cent reported trying to avoid
tourist clients. One half of the respondents reported
that they had ever had an STD. Of these 90 per cent
reported having an STD two or more times. Sixty per
cent reported self treatment with various drugs while
40 per cent had visited a doctor for treatment at least
once. Informal conversations with workers revealed a
reluctance among some to visit health-care providers
because of the stigma of their homosexual activity.
104
Condom beliefs and general condom use
A series of open-ended questions were asked to
elicit condom beliefs from workers. In response to
questions about the ‘good things’ about condoms,
the workers replied that they were safe and they
prevent diseases (60%), they are clean (30%) and
they prevent pregnancy (30%). ‘Bad things’ about
condoms were that they decrease pleasure. They
also said that men with frequent partners should
use condoms (56%). Seventy per cent said that all or
some of their gay friends like condoms and the main
reason that they like them is to prevent illness. Ninety
per cent thought that condoms prevent AIDS and all
knew of sources for condoms in Bali.
Social & Behavioral
Ninety-five per cent of the workers had used a
condom in the last month with the main reason for
use being to prevent illness. Seventy per cent keep
them at their residence and sources for condoms
include the apotik (drug store or chemist 43%), clients
(29%), and gay friends (13%). Almost all workers had
discussed condoms with clients and many claim to
ask clients to use condoms. Twenty four per cent
reported that they ask all clients to use condoms, 24
per cent ask those who they do not know or who look
suspicious, 35 per cent ask all foreign clients, and 18
per cent ask foreign clients that they do not know.
Seventy-two per cent have had clients who refuse to
use condoms.
General sexual history
Most of the workers first had sex with a man when
they were in their teens: 35 per cent at age 14 or less,
40 per cent at age 15-16, and 25 per cent at 16 or
more. Forty-five per cent of the workers were paid
for their first sex with a man. Fifty-nine per cent have
had sex with a woman. Respondents had worked for
an average of 3.1 years with a range of two months
to nine years. Thirty per cent of respondents had
worked as CSWs only in Bali, 60 per cent had worked
in Jakarta or Surabaya and ten per cent had worked
in Batam or Malaysia. The workers generally return
to their home village for holidays (85%), and some
(35%) are usually sexually active on these visits.
Many of those men interviewed identify themselves
as gay, although some are primarily heterosexual in
orientation.
Most workers work seven days each week and most
have one client per day with a reported average
of 5.9 clients each week. The median earnings per
week was US$75 and the range was from US$23 to
US$125. Hotel or retail workers in the Kuta area would
probably receive a salary averaging $50 or less per
week. In addition to cash, most workers also receive
nonmonetary payments such as food or clothing.
Workers report having clients who include Japanese
men (100%), Caucasian men (85%), and Indonesian
tourists (90%), as well as Indonesian businessmen
(80%), university students (45%), civil servants (30%),
and schoolboys (20%). Nearly all (95%) report being
with clients both for a short time and all night but 72
per cent report that they are with most clients for a
short time.
Table 2 shows the frequency of sexual acts requested
by clients and the percentage of workers who agreed
to perform each of these acts. Anal intercourse, both
insertive and receptive, was the most common act
requested and almost all workers would agree to
perform these acts. Masturbation of the client and
the client masturbating the sex worker was the
next most frequent practice and all workers would
agree to this practice. Oral intercourse followed, with
almost all workers agreeing to perform. Rimming,
tongue to anus, the last practice asked about, was
less common.
Sexual experience in the last week
Workers were asked detailed questions about their
sexual experience in the last week. They had an
average of 5.2 clients in the last week, with 4.1 of
these new clients and 0.8 repeat clients. Two workers
reported new female clients in the last week. Fortythree per cent of the workers had an intimate male
non-paying partner and 32 per cent had a casual
non-paying partner. Sixty per cent of workers had
an Indonesian client from Bali, 60 per cent had an
Indonesian client from outside Bali, and 90 per cent
had a tourist client from outside Indonesia.
Table 3 shows the frequency of experience with oral
and anal intercourse in the last week for sex workers.
Most workers had experienced both insertive and
receptive anal intercourse and many episodes took
place without condoms. Oral intercourse was also a
common practice and there was almost no condom
use for oral intercourse.
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Social & Behavioral
Male tourist clients of sex workers
Demographic characteristics
Male sex workers report that their clients include both
Indonesians and foreign clients. This study includes
only foreign clients who may be either tourists or
residents engaged in a variety of business activities.
These clients reported permanent residence in a
number of countries with 42 per cent residing in
Europe, 21 per cent in Australia and others from the
United States, Japan, and other countries (Table 4).
Their age ranged from 23 to 53 with a mean age
of 34.8 years. One-third of respondents had been
previously married to a woman, but none was
currently married. One third had a current male life
partner. Respondents tended to be highly educated
70 per cent having attended college or university,
and an additional 16 per cent having received a
postgraduate degree. As a group they tended to be
frequent travellers, with almost 80 per cent having
previously visited Bali. For many respondents, these
visits were longer than the average tourist stay
with almost half having been in Bali seven or more
weeks. This latter group consisted primarily of people
engaged in business activities who made multiple
visits. Most respondents were travelling alone. Many
men had visited other countries in the region in the
previous two years, including Thailand (58%) and
other Asian countries. Their occupations included
sales and business, designers and artists, teachers,
and other professional and non-professional
occupations.
AIDS knowledge
The clients were also asked a series of open-ended
questions about AIDS. The most important sources of
106
information for clients were gay media, friends and
other media including newspaper and television.
They reported that AIDS could be transmitted by
blood (58%), needles (53%), sex (48%), anal sex
(48%), and transfusions (37%). The majority of clients
said that it was either unlikely or very unlikely (63%)
that they would get AIDS. The modal reason for the
low risk was careful or safe sex (45% of all clients). For
those who thought that it was likely, 33 per cent gave
‘risky sex’ as the reason for their higher risk. Almost all
of the clients (95%) reported taking actions to avoid
getting AIDS and these included careful, safe sex
(50%), use of condoms (50%), and having decreased
the number of partners (39%).
Sexually transmitted diseases
Clients were asked similar questions concerning
their knowledge and perceived risks of contracting
other STDs. Relatively high levels of knowledge of
STDs were observed with 90 per cent of respondents
mentioning syphilis and gonorrhoea, and an
additional 80 per cent adding herpes genitalis.
Most frequently mentioned symptoms of STDs
included dysuria (53%), discharge (47%), sores on
the penis (37%) and swelling of the genitals (32%).
Respondents thought it likely that male sex workers in
Bali suffered from STDs with 53 per cent mentioning
AIDS, 37 per cent gonorrhoea, 26 per cent herpes and
26 per cent reporting syphilis as likely illnesses of sex
workers in Bali. One third stated that it was difficult to
know if a sex worker had one of these diseases, while
the remainder felt they could tell by looking for sores
on the penis (42%), discharge (32%), or observing
if the sex worker had pain on urination. Nearly half
Condom beliefs and general condom use
Clients were asked a shorter, slightly different set of
questions about condom beliefs. They reported that
people use condoms to prevent infection (80%), for
AIDS prevention (26%), and to prevent pregnancy
(74%). The only common reason that people like
condoms was for AIDS prevention and people do
not like them because they cause an interruption
(53%), they decrease sensation (37%), they are a lot
of trouble to use (32%), and they have an unpleasant
smell or taste (26%). More than half of the men did
not know of a source of condoms in Bali and 84 per
cent said they had never obtained one there.
6.4 different sex workers, with a range from one to 23.
Most reported that they were usually with a prostitute
for a short time (68%) but 50 per cent reported at least
one all-night encounter. Some clients also reported
being with a prostitute for several days (19%) or long
term (6%). The average payment was about US$5 and
58 per cent of clients gave a non-monetary payment
such as food or clothing.
Sexual experience in the last week
Clients were also asked about their recent condom
use. Twenty-five per cent used a condom at their last
sexual encounter with a sex worker and 35 per cent
at last sexual encounter with a partner who was not
a sex worker. Nearly 85 per cent have asked a sex
worker to use a condom and 44 per cent have been
asked by a sex worker to use a condom. Forty-one
per cent carry condoms with them. Eighty-one per
cent use a lubricant with condoms and 19 per cent
use lubricated condoms.
The clients reported paying a mean of 1.7 sex
workers (range 1-4 partners) a mean 1.9 times (range
1-5 times) in the last week. Eighty per cent of their
partners were Indonesian and 17 per cent were
other tourists (including one female tourist). Table 5
summarizes the sexual practices reported in the last
week by tourist clients. Masturbation was the most
common practice, with oral intercourse the second
most common. There was a smaller amount of anal
intercourse reported both with and without condoms.
Rimming (tongue to anus) was also reported with
both sex workers and with other partners.
It should be noted that CSWs report more recent
experience with anal intercourse than clients report.
These differences may be due to several factors.
First, both are small samples that do not consist of
matched partners. The clients who were interviewed
comprised few or none of the interviewed sex workers’
clients. Secondly, the clients may not proportionally
represent all nationalities of tourist clients.
Underrepresentation of nationalities for whom anal
intercourse is a more common practice could cause
a low estimate of its prevalence. Thirdly, Indonesian
clients were not interviewed and experiences with
Indonesians are included in the CSWs’ reports.
Underreporting by the clients could also have been
a factor, although this is unlikely since they reported
higher levels of anal sex with unpaid partners.
General sexual history
Alcohol and drug use
Clients’ age at first sexual relations with a man ranged
from eight to 31 years with 21 per cent aged less than
14. Eighty-four per cent had had intercourse with a
woman. Most had first paid for sex in their late 20s
and early 30s. When asked what they enjoy when
they are with sex workers, 25 per cent said that they
liked to talk with them, 81 per cent said they enjoyed
the sexual activities, and 44 per cent. said that they
enjoyed their companionship. Clients had paid sex
workers a mean of 6.9 times in the lastmonth, with
a range from one to 23. They had paid an average of
Heavy use of alcohol by clients was reported by both
sex workers and by clients. Ninety per cent of the
sex workers report that they have clients who are
drunk and 85 per cent of these workers use alcohol
themselves before or during sexual encounters.
Eighty-three per cent of the clients report that they
become intoxicated in Bali. Forty-four per cent report
giving alcohol or drugs to sex workers.
Clients were asked about their current condom use
in general. Twenty-five per cent reported that they
do not use condoms with any partners including
CSWs, lovers and casual partners. Another 35 per cent
reported that they always use condoms with lovers
or intimate partners, 53 per cent always use condoms
with casual partners, and 56 per cent always use
condoms with CSWs. Sexual practices may differ for
different types of partners.
In contrast to this, use of other drugs may be much
less common in Bali. Only 16 per cent of clients
107
Social & Behavioral
(44%) of the clients reported having ever had an STD
themselves with 21 per cent reporting having seen a
doctor for an STD in the last six months.
Social & Behavioral
reported having used other drugs in Bali. None
of the sex workers reported intravenous drug use
themselves and only five per cent of clients reported
ever using intravenous drugs. However, their past
histories imply more risk of HIV infection: 48 per
cent of clients have had sex with someone who was
an intravenous drug user (24%) or probably was an
intravenous drug user (24%).
two and three of the ARRM model, the commitment
and enactment stages, interventions should
include skills development in condom negotiation
and use. Interventions among sex workers could
take advantage of social networks existing in the
community. Education about these diseases and the
development of skills to negotiate condom use and
safer sexual practices could be organized through
these networks.
Summary and discussion
Several limitations of this study must be kept in mind.
The data come from small, convenience samples and
thus, generalizations to Bali and to other areas of
Indonesia are limited. Only English-speaking tourist
clients were interviewed, although sex workers
report their clients to include local Indonesians and
Indonesian tourists, and tourists from other Asian
countries. Because of difficulty of recruitment, both
prostitute and client data may undercount longterm relationships. Short-term visitors are probably
underrepresented in the client sample and higherpriced sex workers may also be underrepresented. It
should also be noted that the data are self reports on
sensitive topics that are not easily verified.
The data indicate that there is a very active community
of male sex workers and male clients in Bali that is
at risk of transmission of AIDS infection. Male sex
workers have limited knowledge of AIDS and STDs.
Knowledge of transmission of these diseases is weak
and they are unaware of asymptomatic transmission.
Multiple sexual partners and frequent anal intercourse
put the prostitutes at risk. Condom use is low and
prostitutes possess ambivalent attitudes about
their use; they frequently experience STDs and selftreatment with antibiotics is common as they report
stigmatization by health care providers. These men
are characterized by considerable mobility and many
are sexually active on frequent travel and home visits
to other parts of Indonesia. In terms of the ARRM
model, many workers were at stage one, the labelling
stage. The prostitutes had inaccurate information
about AIDS and other STDS and proposed ineffective
strategies such as choosing ‘clean’ partners for risk
reduction. As discussed below, interventions with
these men should begin with messages that focus
on which behaviours lead to HIV and STD prevention
to influence labelling of high-risk behaviours as
problematic. As more sex workers progress to stages
108
The non-Indonesian tourist clients, in contrast, have
considerable knowledge of AIDS and STDs. However,
multiple sexual partners, including both sex workers
and other tourists and ambivalent attitudes toward
condom use, resulting in irregular use, put the
clients and their sexual partners at risk of infection.
Many were unaware of sources of condoms in Bali
and condoms are not readily available at places
where sexual encounters take place. High levels of
alcohol use were reported before and during sexual
encounters and may be a factor in increasing risky
sexual behaviours. The clients have histories of STD
infection and many report travel to countries with
higher seroprevalence such as Thailand. In terms
of the ARRM model, the clients have in general
moved beyond stage one, the labelling stage, into
commitment and enactment stages. Obstacles to
moving toward the enactment stages in this group
may include negative beliefs about condoms as well
as the unavailability of good-quality condoms in Bali.
An additional obstacle may be that many of their
Indonesian partners do not generally feel susceptible
to HIV infection.
Health-care services that provide appropriate
STD diagnosis and treatment without disapproval
also need to be developed for workers in the area.
Similarly, services for clients are also lacking. It should
be noted that both groups have sufficient income
to pay for services, so that once established, the
services could become self supporting. In addition,
increasing availability of good quality condoms and
water-soluble based lubricants for both sex workers
and clients should enhance disease prevention.
These should be readily available at the sites where
sex workers and clients meet, as well as in places of
lodging for tourists and other places where sexual
encounters take place.
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References
Social & Behavioral
AIDS and STD Knowledge, Condom Use and
HIV/STD Infection among Female Sex
Workers in Bali, Indonesia
K. Ford1
D. N. Wirawan2
B. D. Reed1
P. Muliawan2
M. Sutarga2
1
2
University Of Michigan, Ann Arbor, Michigan, USA.
Kerti Praja Foundation, Denpasar, Bali, Indonesia.
AIDS Care. 2000 Oct;12(5):523-34
Routledge
111
Abstract
The objectives of this paper were to examine changes in AIDS/STD knowledge and behaviour from 1992–1998, current levels of STD infection
and psychosocial and demographic determinants of condom use and STD infection among female sex workers. Data for the study were drawn
from cross-sectional surveys of female sex workers conducted in 1992, 1994 and 1997–8. For each survey, women participated in a face-to-face
interview in the brothel complexes. Survey questions included information on AIDS/STD knowledge, demographics, sexual history and psychosocial
factors related to condom use. After the last survey, women were offered a vaginal exam for STD diagnosis and treatment. Sera were tested for HIV
infection (anonymous, Elisa/Western blot) and syphilis (TYPHA, RPR). Cervical mucous was tested for chlamydia (LcX), gonorrhea (LCx), herpes (pcr)
and HPV (pcr). Knowledge of AIDS and awareness of STDs has increased tremendously in this population since 1992. Reported condom use has also
increased substantially (69.9%). Perceived susceptibility toward HIV infection remains low. Ineffective preventive strategies such as medication
use continue to be common. HIV infection remains very low in this population (0.2%), although the prevalence of other STDs such as gonorrhea
(60.5%), chlamydia (41.3%) and HPV (37.7%) were very high. STD knowledge and self-efficacy were significantly related to condom use as were
the sex workers’ perceived susceptibility to STD and HIV infection. Women with a larger number of partners were more likely to be infected with
gonorrhea, chlamydia and HIV. Women who had come to Bali recently were more likely to be infected with HIV and gonorrhea.
Introduction
The size of the HIV epidemic in Asia has increased
tremendously in the last five years (Weniger & Brown,
1996). Indonesian Ministry of Health data suggest
that although it is currently low compared to some
neighbouring countries, the number of people
infected in Indonesia is increasing (1,080 by January
2000), with many of these cases identified among
sex workers and clients throughout the Indonesian
islands (Cases of HIV/AIDS in Indonesia, 2000).
A series of behavioural studies have been conducted
among prostitutes and clients in Bali, Indonesia since
1992 (Ford et al., 1994a,b; 1996; Wirawan et al., 1994).
Bali is an island of about 3 million people that receives
a large number of migrants each year due to its large
tourism industry as well as its garment, fishing and
other industries. These migrants include short- and
long-term tourists, as well as male and female workers
from other Indonesian islands. As documented
in earlier research, there are several groups of sex
workers on the island including those serving tourist
and domestic clients. This study focuses on female sex
workers who are employed in low price brothel areas
around Denpasar. These women are mainly migrant
workers from East Java. Almost all are of the Muslim
religion. The clients of these women are Javanese
and Balinese short- and long-term residents of Bali. A
more qualitative study of these women was published
earlier (Wirawan et al., 1994).
Surveys of women working in low price brothels
in Bali, Indonesia were conducted in 1992–3, 1994
and 1997–8. These brothels consist of complexes
of 50–300 women who work in units of 3–15 CSWs
(commercial sex workers), with each unit managed
by a pimp (germo). Frequent raids upon brothels by
local government officials prevent an accurate count
of the number of sex workers employed at any given
time, but it is believed that the total number of sex
workers in the area surrounding the provincial capital
of Denpasar is about 1,250.
The objectives of this paper are: (1) to examine the
changes in AIDS/STD knowledgeand behaviour
over time among these women; (2) to examine the
current levels of STD infection; and (3) to examine
the psychosocial and demographic determinants of
condom use and STD infection. Several psychosocial
models of health behaviour offer explanations
forcondom use. Concepts for hypothesis testing in
this paper have been drawn from two models:
(1) the Health Belief Model (HBM; Rosenstock et al.,
1994), and
(2) social cognitive theory(Bandura, 1994). The HBM
posits that an individual’s actions are based
on beliefs, including perceived susceptibility,
severity of the illness and barriers to prevention.
From this theory we have included measures
in these studies of AIDS and STD knowledge,
condom knowledge, condom beliefs and
113
Social & Behavioral
AIDS and STD Knowledge, Condom Use and
HIV/STD Infection among Female Sex
Workers in Bali, Indonesia
Social & Behavioral
perceived susceptibility to STD and HIV infection.
The HBM is often expanded to include measures
from social cognitive theory. This theory views
learning as a social process influenced by
interactions with other people. Self-efficacy, an
essential component of the theory, is the person’s
belief that she or he is capable of performing a
behaviour in a given situation. From this theory
we have included ameasure of condom selfefficacy.
Methods
The data for this study are drawn from a series of
cross-sectional studies conducted in Bali, Indonesia.
The earliest project, the Udayana-Michigan AIDS
behavioural study was conducted from February
1992 to November 1993 (Ford et al., 1994a). The
study included interviews with 614 female sex
workers, as well as interviews with male clients and
male sex workers. Data from the 407 women who
were interviewed in low price brothels are included
in this paper.
Data are also included from a second series of surveys
conducted in the low price brothels in 1994 as part of
an evaluation of a behavioural intervention (Ford et
al., 1996). In this study, 300 women were interviewed
in each of two rounds of data collection about six
months apart.
Recently, an intervention study has begun and data
from the baseline survey for this study are included
in this paper. From October 1997 through January
1998, 631 women from low price brothels in four
areas in and near Denpasar participated in personal
interviews at the brothel sites and STD examinations
in nearby clinics.
Questionnaires for these surveys were developed
using qualitative data from focus groups and indepth interviews that were conducted in 1990–91
(Wirawan et al., 1994) and include questions on AIDS
and STD knowledge, condom attitudes and beliefs,
self-efficacy, norms, sexual practices and condom
use. Most of the questions in these surveys are closed
ended. The interviews for the 1992–93 behavioural
study lasted 1–2 hours, while shorter interviews
(30–60 minutes) were used in 1994 and 1997. The
interviewers for the study were Balinese and Javanese
males. Male interviewers were selected because
women in the complexes were more accepting of
114
male interviewers than of female interviewers since
they were perceived as being more accepting of the
sex workers than women who are not sex workers.
Training for the interviewers included an orientation
to the study site, study of the questionnaire,
interviewing practise and information on AIDS/STDs.
Interviews with female sex workers were conducted
in private settings at the complex sites.
Sampling for the 1992–93 and the 1994 studies was
conducted by listing pimps and selecting pimps
from each site with probability proportional to
size. After a pimp was selected, all of the women
who worked for him/her were interviewed. For the
1997–98 survey, all women in five brothel locations
were interviewed. In each study, almost all of the
women who were asked to participate completed
an interview. Response rates for the interviews were
close to 100%. In 1997–98, of the 631 women who
completed an interview, 600 agreed to the physical
exam for STD diagnosis. Measures from the survey
interviews were as follows:
Age. Age of women was measured in years.
Education. Education was reported as years of
school completed.
Marital status. Marital status was reported as
married, widowed, divorced, separatedand never
married.
Number of living children. Women were asked how
many children they had who werestill living.
Religion. Women were asked about their current
religion, Muslim, Hindu, Christian orother.
Time working in Bali. Women were asked how long
they had been working in Bali as a sex worker.
The response was recorded in months.
AIDS knowledge. A series of 21 questions were
asked about AIDS transmission and prevention
(see Appendix). To create a knowledge score, a
correct response was scored one and an incorrect
response zero. The scores were then totalled to
create a knowledge score.
STD knowledge. A series of 11 questions were
asked about STD symptoms, prevention and
treatment (see Appendix). A knowledge score
was created with the same procedure used for
AIDS knowledge.
Preventive practices. Women were asked
open-ended questions about how they
protectedthemselves from AIDS and other STDs.
Common responses such as ‘use condoms’ or
STD assessment
In 1997–98, each woman was also offered a physical
exam for STD assessment. About 95% of the women
consented to a vaginal exam. Woman traveled
to a nearby clinical site for the exam. Samples of
cervical mucous were tested for Nesseria gonorrhea
(LCx,Abbott Laboratories, Abbott Park, Illinois),
Chlamydia trachomatis (LAX, Abbott Laboratories,
Abbott Park, Illinois), Herpes simplex I and II (pCR) and
Human Papilloma virus (pCR), trichomonas (culture,
BioMed Diagnostics, San Jose, California, USA), and
candida (culture). Serum was tested for syphilis (TPHA,
RPR. (8)) and HIV (anonymous) (Elisa/Western Blot).
Laboratory tests for syphilis, trichomonas and candida
were processed at Kerti Praja Foundation in Denpasar,
Bali. The testing for gonorrhea, chlamydia and HSV
was conducted at the University of Michigan Hospital
Clinical Microbiology laboratories. The PCR testing for
HPV was conducted at Wayne State University. The HIV
testing was conducted at the laboratories of the Naval
Medical Research unit in Jakarta, Indonesia.
Statistical methods
Differences between proportions were assessed
with t-tests. Multiple regression analysis was used
to assess the significance of factors for continuous
dependent variables. Logistic regression was used
to assess significance for dichotomous dependent
variables. In the multivariate analyses, the variables
representing sexually transmitted diseases are coded
1 if the woman had the disease and 0 otherwise.
The sample size was reduced for the multivariate
analyses due to the inclusion of variables that were
only available for women who worked in the last day.
These variables were condom use and number of
clients in the last day.
Results
Demographics
The mean age of the women in the study was about
25.8, with a range from 14 to 47. Most women had
Table 1. Knowledge and perceived susceptibility to AIDS/STDs of female sex
workers in low price brothels, Bali, Indonesia, 1997– 98
Measure
Heard of AIDS
1997– 98
1994 (postintervention)
1994 (preintervention)
1992– 93
A person with AIDS can look healthy
1997– 98
1992– 93
Transmission through casual contact
1997– 98
1992– 93
CSWs are at risk for AIDS
1997– 98
1992– 93
89% (600)
89% (300)
33% (300)
51% (407)
39%
50%
21%
17%
51%
44%
62%
59%
87%
88%
74%
25%
115
Social & Behavioral
‘take antibiotics’ were coded for each woman.
Perceived susceptibility to AIDS/STDs. Women were
asked if given the preventive practices that they
use, did they think that they were at risk for AIDS
or STDs. Responses were yes/no, maybe yes/
maybe no, and don’t know.
Condom beliefs. Women were asked openended questions about the advantages and
disadvantages of condoms. Responses were
coded 1 if the women mentioned that factor and
0 otherwise.
Condom knowledge. The condom knowledge
score is derived from a series of five questions on
appropriate condom use (see Appendix). Each
correct answer adds one to the score.
Condom self-efficacy. Condom self-efficacy is
derived from a set of six questions that ask how
sure the woman is that she can tell a client to use a
condom, buy condoms, put a condom on a client
and other behaviours. The questions are listed in
the Appendix. The answers were coded 1 = not at
all sure, 2 = not very sure and 3 = very sure. The
responses to each question were added together
to construct the scale. The alpha reliability
coefficient for the scale was 0.83. Condom use. In
1997–98, condom use was measured as number
of clients the woman used a condom with for
vaginal sex in the last day, divided by number of
clients the woman had vaginal sex with in the last
day, times 100. This variable was the same in 1994,
but in 1992–93 it refers to the week before the
interview rather than the day before. Additional
condom use measures were not developed for
other types of intercourse due to low frequency
of reporting. A related measure, the percentage
of clients asked to use condoms was computed
as the number of clients who were asked to use a
condom for vaginal sex, divided by the number of
clients with whom they had vaginal sex in the last
day, times 100. A final measure was whether or not
the woman had vaginal sex without a condom the
day before the interview (1 = had unprotected sex,
0 = did not have unprotected sex).
Social & Behavioral
AIDS knowledge score 1997– 98 (range 5 0– 21)
Mean
Heard of STDs 1997– 98
STD knowledge score 1997– 98 (range 5 0– 11)
Mean
Preventive practices for AIDS 1997– 98
Use condom
Get injections/exams
Take antibiotics regularly
Drink jamu
Clean genitals
Do you have a chance to catch AIDS? 1997– 98
Yes
Maybe yes/maybe no
No
Don’t know
Do you have a chance to catch STDS? 1997– 98
Yes
No
Maybe yes/maybe no
Don’t know
Table 2. Condom use among female sex workers in low price brothels in Bali, Indonesia,
1997– 98
10.84
94%
Measure
5.75
85%
37%
56%
21%
16%
14%
8%
83%
9%
13%
12%
67%
8%
some elementary schooling (mean 5 4.6 years). The
majority or women were divorced (66%), with a
smaller percentage widowed (7%), separated (9%),
married (6%) or never married (13%). About 69% of
women had a living child and most reported Islamic
religion (95%). The women reported that they had
been working in Bali for a mean of about 13 months
and a median of six months. These demographics are
similar to those reported in earlier surveys in this area.
AIDS/STD knowledge
Awareness of AIDS has increased tremendously in
this area since the first survey was conducted (Table
1)(p < 0.01). In 1992–93, 51% reported ever hearing
of AIDS and this had increased to 89% by 1994
Value
Condom beliefs 1997– 98
Condoms prevent AIDS
Condoms prevent STDs
Condom knowledge (mean) 1997– 98
Condom self efcacy (mean) 1997– 98
Total number of clients yesterday 1997– 98
Mean
Range
Clients asked to use condoms
Condom use vaginal sex
1997– 98
1994 (post-intervention)
1994 (pre-intervention)
1992– 93
Number of new clients yesterday 1997– 98
Mean
Range
New clients asked to use condoms
Condom use vaginal sex new clients
Number of repeat clients yesterday 1997– 98
Mean
Range
Repeat clients asked to use condoms
Condom use vaginal sex repeat clients
Percentage of female sex workers who had vaginal sex
Without a condom with at least one client yesterday 1997– 98
In the past month, has an intimate partner/boyfriend/husband
ever used a condom with you? 1997– 98
Yes, used a condom
No, hasn’t used a condom
Haven’t had sex with an intimate partner/boyfriend/husband
in the last month
N
Independent variable
Age
Education
Time in Bali
Unpaid partner 7 days
AIDS knowledge
STD knowledge
Possible AIDS
Possible STDs
Self-efcacy for condom use
Condom knowledge
# of clients yesterday
Constant
N
Coefcient
0.18
2 1.04
2 0.01
2 1.85
0.07
2.65
5.17
2 5.61
1.39
6.04
3.34
2 0.21
2 53.62
R2
F
407
t statistic
0.54
2 1.86*
2 0.13
2 1.76*
0.16
2.97***
1.92**
2 1.95**
0.31
8.62***
1.50
2 0.26
0.23
10.09***
*p , 0.10; **p , 0.05; ***p , 0.01
116
2.9
0– 13
73.3%
69.9%
69.8%
31.3%
19.0%
1.7
0– 11
76.8%
69.4%
1.3
0– 9
71.0%
70.5%
46.7%
29%
22%
48.8%
631
(p < 0.01). Awareness of asymptomatic infection
has also increased from 17% in 1992–93 to 38% in
1997. Furthermore, among those who are aware of
AIDS, about half of the female sex workers continue
to report that AIDS can be spread through casual
contact such as shaking hands or eating from the
Table 3. Logistic and linear regression analysis of factors related to condom use among female sex workers in low price brothels.
Bali, Indonesia, 1997– 98.
Linear model: dependent
variable percentage condom
use in last day
72%
91%
4.3
13.0
Logistic model: dependent
variable at least one client w/o
a condom in last day
Coefcient
2 0.01
0.05
0.01
0.12
0.02
2 0.18
2 0.12
0.35
2 0.41
2 0.45
2 0.11
0.30
6.20
2 2 log likelihood
Chi-square
407
Odds ratio
0.99
1.05
1.00
1.12
1.02
0.83***
0.88
1.41*
0.66
0.63***
0.90
1.35***
456.91
99.31***
Table 4. Logistic regression analysis of factors related to sexually transmitted diseases and condom use among female sex workers, Bali, Indonesia, 1997– 98
Independent variable
Coefcient
2 0.08
Age
Education
0.06
2 0.00
Time working in Bali
2 0.03
Unpaid partner in last 7 days
2 0.04
AIDS knowledge
STD knowledge
0.10
Possible catch AIDS
0.17
2 0.15
Possible catch STDs
0.65
2 0.16
Self efcacy for condom use
2 0.07
Condom knowledge
2 0.00
# of clients yesterday
Condom use yesterday
0.00
Constant
3.06
2 2 log likelihood
481.77
Chi-square
38.10***
N
393
Odds ratio
0.92***
1.07*
0.99
0.96
0.96
1.10
1.19
0.86
1.92**
0.85**
0.93
1.00
1.00
HPV
Coefcient
2 0.05
0.01
2 0.03
0.20
0.04
0.01
2 0.11
0.25
2 0.07
0.09
0.05
2 0.02
2 0.01
2 0.78
442.20
33.93***
355
Odds ratio
0.94**
1.00
0.97***
1.22**
1.04
1.00
0.90
1.28
0.82
1.10
1.06
0.98
0.99**
Nesseria gonorrhoea
Coefcient
2 0.09
0.03
2 0.02
0.00
2 0.07
0.10
2 0.18
2 0.40
2 0.30
2 0.05
2 0.07
0.08
2 0.00
5.35
240.82
13.57
378
Odds ratio
0.91***
1.03
0.98**
1.00
0.93**
1.11
0.84
0.67*
0.74
0.95
0.93
1.09
1.00
Trichomonas
Coefcient
2 0.04
0.01
0.01
2 0.29
2 0.05
0.01
2 0.63
0.47
0.10
2 0.08
2 0.22
2 0.16
2 0.00
2.11
233.92
20.27
393
Odd ratio
0.96
0.99
1.01
0.74*
0.95
1.00
0.53
1.60
1.11
0.92
0.80
0.86
1.00
Syphilis
Coefcient
0.02
2 0.20
0.00
0.01
0.06
0.01
0.03
0.39
0.28
0.12
0.33
0.17
2 0.00
2 7.06
269.22
23.81**
398
Odds Ratio
1.02
0.82***
1.00
1.01
1.06
1.01
1.03
1.48
1.32
1.13
1.39
1.18**
1.00
*p , 0.10; **p , 0.05; ***p , 0.01.
same plate. By 1994, most sex workers reported that
sex workers were at risk for acquiring AIDS. Out of 21
questions on transmission and prevention of AIDS
(see Appendix), the women answered only about
half correctly. Almost all of the women had heard of
STDs (94%), although only about half of thequestions
about STD symptoms and treatment were answered
correctly (See Appendix 1).
The women were also asked an open ended question
about preventive practices for AIDS. Many responded
that they use condoms (85%), but ineffective
strategies such as taking antibiotics regularly (56%),
getting injections or exams (37%), drinking jamu
(21%) or cleaning the genitals (16%) were also
mentioned. Similar practices were reported for
prevention of STDs in general (data not shown).
The women were asked if given what they do, do
they still have a chance to catch AIDS and most
(83%) thought that they did not have a chance. Most
women also reported that their chances of catching
STDs were low.
Condom knowledge, beliefs and selfefficacy
The most common condom beliefs reported were
that condoms prevent AIDS and that condoms
prevent STDs (Table 2). The average score on the
condom knowledge questions was high—a mean of
4.3 out of a maximum of five. Condom self-efficacy
was also fairly high—a mean of 13.0 out of 18.0.
Condom use
Reported condom use with clients has increased
tremendously since 1992 (19 to 70%) (p < 0.01).
In 1997–98, the women were asked a series of
questions about condom use with all clients, repeat
clients and new clients. Unlike many other studies,
reported condom use with new and repeat clients
did not differ markedly. Although reported condom
use was at a high level (about 70%), almost half of
the women had unprotected vaginal sex in the last
day with at least one client. About half of the women
(51%) had sex with someone who was not a client—
an intimate partner, a boyfriend or a husband in the
last month. Of these women, more than half (57%)
used a condom with that partner.
STD prevalence
The levels of STD infection at the time of interview
were quite high in these women for several diseases
(Nesseria gonorrhea (60.5%), chlamydia (41.3%), HPV
(37.7%), trichomonas (11.3%) and syphilis (10.9%)).
Levels of herpes simplex infection were much lower
(2%). One woman tested positive for HIV infection.
Determinants of condom use
Demographic, knowledge and psychosocial factors
were tested for their association with condom use
(Table 3). Two measures of condom use were used:
the percentage condom use in the last day and
whether or not women had unprotected sex with at
least one client in the last day.
Few demographic variables were related to condom
use. The only highly significant association was
with unprotected sex with one partner in the last
day and number of partners. Women with more
partners were more likely to have unprotected sex
(p < 0.01). Two other variables, education and having
vaginal sex with an unpaid partner in the last seven
117
Social & Behavioral
Chlamydia
trachomatis
Social & Behavioral
days, were related to condom use at a lower level of
significance (p < 0.10). Both AIDS knowledge and
STD knowledge were tested for association with
condom use. However, STD knowledge rather than
AIDS knowledge was associated with condom use
(p < 0.01). Women with greater STD knowledge
were more likely to use condoms. Several of the
psychosocial measures were tested for association
with condom use. Perceived susceptibility to HIV and
STD infection and self-efficacy for condom us were
significantly related to condom use (p < 0.01). Higher
self-efficacy was associated with more condom use.
Women with a greater perceived susceptibility to STD
infection were less likely to use condoms and more
likely to have had unprotected sex in the last day.
Those with a higher perceived susceptibility to HIV
infection were more likely to have used condoms.
Determinants of STD infection
Table 4 shows logistic regression models of factors
related to sexually transmitted diseases. For
chlamydia, age was related to the prevalence of
infection. Older women had fewer infections (p <
0.01). Education had a weaker relationship with
chlamydia infection. This infection was also related to
the condom belief that condoms prevent AIDS and
to self-efficacy for condom use (p < 0.05). Greater
self-efficacy for condom use reduced the risk of
chlamydia infection.
For human papillomavirus (HPV), the women who
had been working in Bali longer (p < 0.01) and those
women with higher condom use were less likely to be
infected (p < 0.05). Women with an unpaid partner
in the last week were more likely to be infected (p <
0.05). Older women were also less likely to be infected
(p < 0.05). Older women (p < 0.01), as well as women
who had been working in Bali longer, (p < 0.05) were
less likely to have gonorrhea. Women with more AIDS
knowledge were also less likely to have gonorrhea (p
< 0.05). Women who reported a low level of perceived
susceptibility to STDs were more likely to be infected
with gonorrhea (p < 0.10). Only one variable, having
an unpaid partner in the last seven days, was related
to trichomonas infection (p < 0.10).
The logit model for the last STD, syphilis, had only
two significant variables. Education reduced the risk
of infection (p < 0.01) and the number of clients in
the last day increased the risk of infection (p < 0.05).
118
Discussion and conclusion
Knowledge of AIDS and awareness of STDs has
increased tremendously in this population since
1990. Reported condom use has also increased
substantially. However, condom use is still far
from 100% and perceived susceptibility toward
HIV infection remains low. Ineffective preventive
strategies such as medication use were common.
HIV infection remains very low in this population,
although the prevalence of other STDs such as
gonorrhea and chlamydia was very high. These low
levels of HIV infection are consistent with the levels
obtained in the RI-EC AIDS Project (Iven et al., 1997).
The STD rates are also consistent with the high rates
obtained in Surabaya (Joesoef et al.,1997).
STD knowledge and self-efficacy were significantly
related to condom use, as were the sex workers’
perceived susceptibility to STD and HIV infection.
Women with a larger number of partners were more
likely to be infected with gonorrhea, chlamydia and
HPV. Women who had come to Bali recently were
more likely to have HPV and gonorrhea. Finally,
more educated women were less likely to have
syphilis. It should be kept in mind that the findings
of this study from survey interviews are based on
self-report data on sensitive behaviours and thus
may be subject to problems of inaccurate recall and
deliberate concealment. In conducting the study,
the staff attempted to minimize these problems by
careful selection and training of interviewers, by
providing assurances of privacy and confidentiality
to respondents and by careful questionnaire design.
These results are also based on cross-sectional data
and hence causal inferences should be made with
caution.
While the women reported fairly high levels of
condom use, the levels of STD infection remain very
high in this population. While there may be some
overestimation of condom use, even the reported
level allows for a significant amount of unprotected
intercourse. Indeed, about half of the women who
had worked the day before the interview had had
unprotected vaginal sex with at least one client.
In the multivariate results, the women’s age was
not related to condom use, but was related to STD
infection. Since number of clients was controlled
for in these analyses, this result may be due to the
in providing assistance with laboratory procedures in
Bali and in conducting the HIV testing.
The older women may have older clients, whose
level of STD infection may be lower than that of the
younger men. The older women may also be more
experienced in recognizing the signs of STD infection
and consequently be more likely to seek treatment
for their infections.
References
The percentage of clients who were asked to use
condoms (73%) was close to the percentage of clients
who were reported to use condoms (70%). Although
sex workers who have been involved in interventions
may over-report the use of condoms, with appropriate
education, clients may be motivated to use condoms
for several reasons. First, they are often bothered
by STD symptoms. Second, they may spread STD
infections to their wives and other partners and this
may harm these relationships.
There is a strong belief among clients (Sutakertya et
al., 1999), that use of antibiotics and other traditional
medicines can protect clients from all STDs, including AIDS.
If appropriate education were provided to these clients on
the weakness of this practice for prevention of STDs, then
condom use may well increase among these men.
Clearly, further work needs to be done to increase
condom use and timely treatment for STD infection.
The high rates of STD infection suggest the potential
for the spread of HIV infection in this area. The study
results suggest that increasing the level of STD
education and self-efficacy may increase condom use.
Promoting self-efficacy should include improving use
with clients. Furthermore, outreach efforts to further
educate clients may also be effective.
Acknowledgements
This project was supported by grant number 1 R01
MH55942 from the AIDS Program of the National
Institute of Mental Health. We would like to
acknowledge the assistance of Dr Carl Pierson and
Rosemary Hankerd of the University of Michigan
Clinical Microbiology Laboratories in processing
the specimens at the laboratory. We would also like
to acknowledge the assistance of Lucie Gregoire of
Wayne State University in completing the pCRtesting
for HPV. Finally, we would like to acknowledge the
assistance of Drs Andrew Corwin and Maidy Putri of
the Naval Medical Research Unit in Jakarta, Indonesia
BANDURA, A. (1994). Social cognitive theory and exercise of control
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and sexual networks of male and female sex workers and
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FORD, K.,WIRAWAN,D.N., FAJANS, P. (1994b). AIDS knowledge, risk
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A., MEHEUS, A. & SUESEN, N. (1997). HIV still not a major
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JOESOEF, M.R., LINNAN, M., BARAKBAH, Y., IDAJADI, A., KAMBODJI,
A. & SCHULTZ, K. (1997). Patterns of sexually transmitted
diseases in female sex workers in Surabaya, Indonesia.
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ROSENSTOCK, I.M., STRECHER, V.J. &BECKER,M.H. (1994). The health
belief model and HIV behavior change In: R.
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SUTAKERTYA, I.B.,WIRAWAN, D.N., FORD, K., REED, B., BUDIANAYA,
G.N., SEDANA, D. & SUYETNA, D. (1999). The Bali STD/AIDS
study: barriers to condom use among male clients of female
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Appendix: Knowledge and self-efficacy
scale content
AIDS knowledge
(1) Can a person who is already infected with the AIDS virus
appear to be healthy?
(2) Can a person who is already infected with the AIDS virus but
still appears healthy spread the disease to other people?
(3) Can people catch AIDS by exchanging clothes, eating from the
same dish, or shaking hands with the person who is already
infected with the virus?
(4) Can an infected woman who is pregnant spread the AIDS virus
to her unborn baby?
(5) Can a person catch AIDS by urinating in the same place as a
person infected with AIDS?
(6) Do some Indonesians already have AIDS?
119
Social & Behavioral
difference in client mix between the younger and
older sex workers.
Social & Behavioral
(7) Can women who work like you do become infected with
AIDS?
(8) Can these diseases be preventing by not drinking from the
same glass as someone who has STD?
(8) Can AIDS be prevented by taking medicine/getting injections
regularly?
(9) Can these diseases be prevented by not changing sexual
partners?
(9) If a condom is used during sex, can it be used to prevent AIDS,
as long as it does not break?
(10) Can these diseases cause sterility/inability to get pregnant/
have children?
(10) Can a person who gets AIDS be cured?
(11) If a doctor gives medicine for a sexually transmitted disease,
do you have to continue the medicine until it is finished, even
if symptoms are gone beforehand?
(11) Is AIDS spread through:
(a) body sweat
(b) body contact
(12) Can some of these diseases lead to death?
(c) kissing on the mouth
(d) intercourse without using a condom
Condom knowledge
(e) injection drug use
(1) Does a man need to put on a condom when he is ready to
“cum” ejaculate?
(f ) having abortions (equipment)
(g) blood transfusion
(h) injection using used needles
(2) Does a condom need to be held when a man pulls out after
“cumming”?
(i) eating contaminated food
(3) Can a male condom be used more than once if it is washed out
carefully with soap and water?
(j) mosquito bites
(4) Can a condom be used if it seems to be dried out?
(12) Is AIDS always a fatal disease?
(13) Is there any medication that can prolong the life of someone
with AIDS?
(5) When using condoms, is it better to withdraw the penis soon
after “cumming”?
Condom self efficacy
STD knowledge
(1) Can a person who is infected with a sexually transmitted
disease look healthy (without symptoms)?
(1) Here are some other behaviors related to using condoms.
Please tell me how sure you are that you can do these things.
Are you very sure, not very sure of not at all sure that you can:
(2) If all of your clients wear condoms, can you be protected
against catching these diseases?
(a) brave enough to tell a client to use a condom
(3) Can these diseases be prevented by taking antibiotics, such as
tetracycline, before or after having sex?
(c) tell a client to put a condom on or put the condom on
when your partner is high on alcohol
(4) Can sexually transmitted diseases be prevented or treated by
drinking jamu (traditional medicine)?
(d) put a condom on your partner correctly/make sure your
partner uses a condom correctly
(5) Can these diseases be prevented by cleaning the genitals after
sex?
(e) talk with a new client about using condoms before having
sex the first time
(6) Can these diseases be prevented by eating a lot of
vegetables?
(f ) talk to new women in the complex about using condoms
(7) Can these diseases be prevented by using a net when
sleeping?
120
(b) but a package of condoms
Social & Behavioral
Social Influence, AIDS/STD Knowledge,
and Condom Use among Male Clients of
Female Sex Workers in Bali
Kathleen Ford1
Partha Muliawan2
1
2
AIDS Educ Prev. 2002 Dec;14(6): 496–504
Guilford Publications
121
Abstract
The importance of social networks is increasingly being recognized in research on HIV risk behaviors. The objective of this article is to examine
the association of AIDS and sexually transmitted disease (STD) knowledge, perceived susceptibility to HIV/STD infection, condom beliefs,
demographic variables, and peer influence on the condom use of clients of Indonesian sex workers. Data for the study are drawn from the Bali
STD/AIDS study conducted from 1997 to 1999 in Bali, Indonesia. During the project 2,026 men were selected for interviews in low price brothels.
Statistical methods included multivariate regression models. Results of the study showed that younger men, men who have resided in Bali for at
least a year, and more educated men were more likely to use condoms. Furthermore, men with stronger AIDS and STD knowledge and condom
beliefs were more likely to use condoms. Men whose friends knew that they visited sex workers were less likely to use condoms. However, men
who reported that their friends used condoms with sex workers and that their friends encouraged them to use condoms with sex workers were
more likely to use condoms with sex workers. Implications for prevention of HIV infection are discussed.
© 2008 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
The importance of social networks is increasingly
being recognized in behavioral and intervention
research on HIV risk behaviors. The objective of this
article is to examine the association of the social
influence of friends, AIDS/sexually transmitted
disease (STD) knowledge, perceived susceptibility to
HIV/STD infection, condom beliefs, and demographic
variables on condom use with sex workers.
Background
Prostitution exists throughout Indonesia in both
officially organized and unorganized areas (Jones,
Sulistyaningsih, & Hull, 1998). Bali is an Indonesian
island of about 3 million people that receives a large
number of migrants each year due to its large tourism
industry as well as its garment, fishing, and other
industries. These migrants include short- and longterm tourists as well as male and female workers from
other Indonesian islands. As documented in earlier
research, there are several groups of sex workers on
the island including those serving tourist and domestic
clients (Fajans, Wiriwan, & Ford, 1994; Ford, Wiriwan, &
Fajans, 1994, Wirawan, Fajans, & Ford, 1991). This study
focuses on the male clients of female sex workers
who are employed in low price brothel areas around
Denpasar.
The HIV epidemic in Indonesia is growing although at
a slower rate compared with some of its neighboring
countries. The number of people infected in Indonesia
increased to 2,313 by September 2001, with many
of these cases identified among CSWs and their
clients throughout the Indonesian islands (Cases of
HIV/AIDS in Indonesia, 2001). A recent increase has
been noted among drug users. Sentinel surveillance
indicates that HIV prevalence is slowly increasing
among female prostitutes and has reached 2% in
Papua and Riau provinces.
Surveys of women and clients working in low-price
brothels in Bali, Indonesia, were conducted in 1992
to 1993, 1994, and 1997to 1999 (Ford, Wiriwan, Reed,
Muliawan, & Sutarga, 2000). These brothels consist
of complexes of 50 to 300 women who work in units
of 3 to 15 CSWs with each unit managed by a pimp
(germo). Most of these women come from East Java.
They travel to Bali for employment and may return to
Java for holiday visits or for more extended periods
of time before returning to work. Every 6 months,
about half of the women in the complexes will be
new. Clients of these workers are almost exclusively
Indonesian, including those who currently reside both
inside and outside of Bali. The mobility of the workers
and recurring police arrests makes an accurate count
of the number of sex workers employed at any given
time difficult, but it is believed that the total number
of sex workers in the area surrounding the provincial
capital of Denpasar is about 1,250.
Conceptual Frametwork
Concepts for hypothesis testing will be drawn from an
expanded health belief model (HBM). The HBM posits
123
Social & Behavioral
Social Influence, AIDS/STD Knowledge,
and Condom Use among Male Clients of
Female Sex Workers in Bali
Social & Behavioral
a role for beliefs about the consequences of one’s
actions and assumes that the behavior arises after
a rational computation of a set of information.
According to the HBM, health behavior decisions
are made through a computation alanalysis of
susceptibility to a disease, disease severity, and
relative costs and benefits of health-threat-reducing
activities (Rosenstock, Strecher, & Becker, 1994).
Application of this model in our previous Indonesian
work has demonstrated the importance of the HBM
components—health beliefs and susceptibility to
HIV/STD infection in condom use—among female
sex workers and clients (Fajans et al., 1994; Ford,
Wirawan, & Fajans, 1998).
Recently, the HBM has been expanded in HIV
prevention research to include social norms.
Perceptions of behaviors among peers or other
community members may influence risk taking
behavior. The social influence and social learning
that occur insuch networks do so through a variety
of mechanisms including persuasion, modeling of
behavior, exchange of information, sanctioning of
behavior, and creating normative environments that
encourage some behaviors and discourage others.
In the research literature on commercial sex, there
has been an emphasis on peer education for sex
workers, with relatively little attention to the influence
of peers on client risk behaviors. One exception
to this is a behavioral study of youth in Thailand
(VanLandingham, 1995). This study of young Thai men
found that peer pressure was an important factor in
the decision to visit a prostitute. In addition (Leonard
et al., 2000) conducted a peer education study among
transport workers. In this study, transport workers
were trained to perform peer education among other
workers and the intervention had a significant impact
on several measured outcomes. This study examines
the effects of peer knowledge of use of prostitutes
and use of condoms on risk behaviors.
Methods
Sample
The data for this study were collected from 1997
to 1999 in low-price brothels in and near the city
of Denpasar, Bali. All of the large low-price brothel
areas in and near Denpasar were included in the
study. Clients were selected by convenience and
interviewed in a private location in the brothel areas.
A high percentage of clients (about 90%) agreed to
124
participate. Refusal was generally related to time
constraints and not to the subject matter of the study.
Most clients were interviewed after they had sex with
a female sex worker. In total, 2,127 interviews were
conducted. A survey question asked if the men had
been interviewed in the brothels before and about 5%
of the men indicated that they had been interviewed.
Due to possible correlation between interviews, these
second interviews were eliminated from the analysis
leaving 2,026 interviews for analysis.
Procedures
Interviewers for the study included Balinese and
Javanese males who were residing in Bali. A training
session of several days was given to the interviewers
including obtaining informed consent, orientation to
the field situation, probing, asking sensitive questions,
and recording answers. To obtain unbiased responses
in the interviews, field personnel who were involved
in HIV prevention activities such as education and
condom distribution in the area were not included in
the interviewing staff.
Measures
Questionnaires for these surveys were developed
using qualitative data from focus groups and indepth interviews; they include questions on AIDS
and STD knowledge, condom attitudes and beliefs,
self-efficacy, self- and peer norms, sexual practices,
and condom use. Most of the questions in these
surveys were closed ended. The interviews lasted
30-60 minutes. Measures from the survey interviews
included the following:
1. Age. Age was measured in years.
2. Education. Education was reported as years of
school completed.
3. Marital status. Marital status was reported as
married or not married.
4. Migration status. Clients were asked how long
they had been living or working in Bali. This was
coded into five categories: less than 1 month, 1-6
months, 6 months to 1 year, longer than 1 year,
and since birth.
5. AIDS knowledge. A series of 13 questions were
asked about AIDS transmission and prevention
(see Appendix).
6. STD knowledge. A series of seven questions were
asked about STDs (see Appendix).
7. Perceived susceptibility to AIDS. Respondents were
use, did they think that they were at risk for AIDS.
9.
10.
11.
12.
13.
14.
15.
sometimes? Or never?” Responses were coded
4 = always, 3 = often, 2 = only sometimes, rarely,
1 = never. The second measure, condom use last
time, was assessed with the question “The last
time that you had sex with a sex worker did you
use a condom?” Responses were coded 1 = yes,
0 = no.
Results
Demographics
The demographics of the client sample are shown in
Table 1. The number of years of schooling completed
by clients averaged 9.2 years with a range from 0 to
16 years. Clients ranged in age from 14 years to 68
years, with a mean age of 29.3. More than half of all
clients (53.5%) were ageD 20-29 years. Over half of
the men (62%) were not married and 62% were of
urban residence. Very few of the men had recently
arrived in Bali, 41% were born in Bali, and 45% of the
other men had been resident at least one year.
AIDS Knowledge And Preventive Practices
Data on AIDS knowledge and preventive practices
are shown in Table 2. The percentage of clients who
had heard of AIDS was 86%. Out of 15 questions on
AIDS transmission, prevention, and consequences
(see Appendix), the clients got an average of 6.7
correct. Out of seven questions on STDs, clients got
an average of 3.2 correct. Common misconceptions
about AIDS and STDs were that a person with AIDS
can. look healthy (78% incorrect answer), AIDS is
spread by casual contact such as by touching clothes
(60.0% incorrect answer), and AIDS can be prevented
TABLE 1. Demographic Characteristics of Clients, Bali, Indonesia 1997–1999
Variable
Years of education
Mean
Range
Data
9.22 years
0–16 years
Age group
15–19
20–24
25–29
30–34
35–40
40–50
50+
Total
Percent
8.7
27.5
26.0
14.1
8.7
11.1
3.8
100.0
Marital status
Married
Not married
Total
Percent
37.9
62.1
100.0
Residence
Urban
Rural
Total
Percent
62.0
38.0
100.0
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Social & Behavioral
8.
Responses were yes, no, maybe yes/maybe no,
and don’t know.
Perceived susceptibility to STDs. Respondents were
use, did they think that they were at risk for STDS.
Responses were yes, no, maybe yes/maybe no,
and don’t know.
Condom beliefs. Respondents were asked open
ended questions about the advantages and
disadvantages of condoms. Responses were
coded 1 = mentioned belief, 0 = did not mention
belief.
Use of antibiotics. The men were asked if they used
antibiotics before or after sex with a sex worker.
Responses were coded 1 = use antibiotics, 0 = did
not use antibiotics.
Came to brothel with friends. Responses were
coded 1 = yes, 2 = no..
Friends know about respondents’ visits to sex
workers. Responses were coded 4 = all/most, 3 =
half, 2 = Few, 1 = None.
Friends advise respondent to use condoms.
Responses were coded 4 = all/most, 3 = half, 2 =
few, 1 = none.
Friends use condoms with sex workers. Responses
were coded 4 = all/most, 3 = half, 2 = few, 1 =
none.
Condom use. Two measures for condom use were
used in this study. The first measure, regular
condom use, was assessed with the following
questions: “Have you ever worn a condom when
having sex with a sex worker?” “If yes, how often
did you use condoms? Always? Often? Only
Social & Behavioral
Time in Bali
Less than 1 month
1 to 6 months
6 months to 1 year
Longer than 1 year
Since birth
N
Percent
3.5
6.7
3.4
45.3
41.0
100.0
2,036
by taking medicine or an injection (57.6%, incorrect
answer). Similar misconceptions were reported for
STDs. About27%of the clients reported that they
had taken antibiotics before or after sex for STD/HIV
prevention.
Clients were also asked about whether given their
present preventive practices, they were likely to catch
AIDS or other STDs. About 16% responded that it was
likely that they would catch AIDS and 27% responded
that it was likely that they would catch other STDs.
In response to an open-ended question on the
advantages of using condoms,45% reported that
condoms prevent AIDS, 21% reported that condoms
prevent STDs, and 23% reported that condoms are
good for family planning. When asked about the
disadvantages of condoms, there was only one
common response. Condoms are unpleasant or
uncomfortable was reported by 63% or clients.
More than half of respondents reported that they use
condoms at least some of the time with sex workers,
although only 15% reported that they always use
them. The last time that they had sex with a sex
workers, only 32% of clients used them.
Clients often come to the brothel with their friends. At
the time of the interview, about two thirds of clients had
TABLE 2. AIDS Knowledge, Condom Use, and Peer Behavior of Male Clients of Female Sex Workers
Variable
AIDS knowledge
STD knowledge
Took antibiotics before/after sex
Reports condoms prevent AIDS
Reports condoms prevent STDs
Reports condom are good for family planning
Reports condoms are unpleasant
Likely catch AIDS
Yes
Maybe
No
Don’t know
Total
Likely catch STDs
Yes
Maybe
No
Don’t know
Total
Regular condom use with female sex workers
Never Use
Only sometimes/ rarely
Often
Always
Total
Condom use last sex
Came to brothel with friend(s)
Friends know respondent visits female sex workers
None
Few
Half
All
Total
126
Data
Mean = 6.7, Range = 0–15
Mean = 3.2, Range = 0–7.0
27%
45.2%
21.2%
22.6%
62.6%
16.6%
58.5%
12.9%
12.0%
100%
27.0%
39.1%
11.2%
22.6%
100.0%
45.3
27.4
12.6
14.7
100.0
31.8%
66.4%
16.1%
53.2%
9.5%
21.2%
100.0%
come with one or more friends. Most clients also report
that at least some of their friends know that they visit
prostitutes (84%), but most did not report that all (21%)
friends knew about their visits. Almost half (44%) of
respondents did not know if their friends used condoms
with prostitutes, and only a small proportion knew
if half (7%) or all (7%) of their friends used condoms
with prostitutes. Only 29% of clients reported that their
friends urge them to use condoms with prostitutes.
The younger men in the study (less than 35) were
more likely to come to the brothel with friends (73%
vs. 44%, p < .01) and to talk with their friends about
AIDS (58% vs. 49%, p < .01). They were also more
19.5%
22.0%
6.6%
7.3%
44.6%
100.0%
16.1%
54.5%
21.9%
1.7%
5.8%
100%
2,036
likely to report that at least some of their friends use
condoms with prostitutes (38% vs. 29%, p < .05) and
that their friends urge them to use condoms with
prostitutes (32% vs. 19%, p < .01).
Multivariate Analysis
A multiple regression analysis was completed to assess
the importance of demographic factors, perceived
susceptibility to HIV/STD infection, condom beliefs,
AIDS/STD knowledge, and the variables related to
friends on condom use with sex workers (Table 3).
All variables were entered simultaneously. Among
the demographic variables, education and migrant
status were significantly associated with condom use.
TABLE 3. Multiple Regression Models of Factors Related to Regular Condom Use With Female Sex
Workers of Clients
Variable
Age group
b(t,p)
–0.03 (–1.30, .19)
Years of education
0.03 ( 2.78, .00)
Resident more than 1 year in Bali
0.23 ( 2.50, .01)
Marital status
AIDS knowledge
STD knowledge
–0.02 (–0.28, 0.78)
0.06 ( 5.98, .00)
0.09 ( 4.29, .00)
Catch AIDS
–0.26 (–7.20, .00)
Catch STD
–0.29 (–7.02, .00)
0.35 ( 5.25, .00)
Condoms prevent STDs
0.73 ( 7.72, .00)
Condoms good for family planning
0.17 ( 2.28, .02)
Condoms unpleasant
–0.12 (–1.90, .03)
Take antibiotics
–0.12 (–1.78, .07)
Friends know about visits to female sex workers
–0.20 (–5.58, .00)
Friends tell you to wear condoms with female sex workers
0.19 ( 4.86, .00)
Friends use condoms with female sex workers
0.16 ( 5.84, .00)
R2
0.27
F
40.36
N
1,824
127
Social & Behavioral
Friends use condoms with female sex workers
None
Few
Half
All
Don’t know
Total
Friends urge respondent to use condoms with female sex workers
Friends don’t know about visits to female sex workers
None
Few
Half
All
Total
N
Social & Behavioral
Condom use increased with each year of schooling (p
= 0.02), and longer term residents were more likely to
use condoms with sex workers than were other men
p < 0.01). The other demographic variables age and
marital status were not significantly related to regular
condom use.
behaviors and thus may be subject to problems
of inaccurate recall and deliberate concealment.
In conducting the study, the staff attempted to
minimize these problems by careful selection and
training of interviewers, and by providing assurances
of privacy and confidentiality to the clients.
Both AIDS knowledge and STD knowledge were
positively related to condom use p < .01). Those
men with greater knowledge were more likely to use
condoms. Perceived susceptibility to AIDS/STDs was
negatively related to condom use p < .01). Men who
did not use condoms regularly reported that it was
more likely that they would become infected with
AIDS or other STDs.
Another limitation of the study is its cross-sectional
design. Beliefs, norms, and behavior were only
measured at one time point, limiting the causal
inferences that can be drawn from the study. These
data provide support for the use of constructs from
the HBM in developing interventions for clients.
Perceived susceptibility to infection and condom
beliefs were associated with condom use. Use of
antibiotics for prevention of infection has been
noted in this and earlier studies. The belief that all
STDs can be prevented using a dose of antibiotics
is a strong belief among clients that may be difficult
to change.
Condom beliefs were also related to condom use.
Men who reported that condoms were good for
protection from AIDS or STDs p < .01) or were good
for family planning (p = .02) were more likely to use
condoms. Men who reported that condoms were
unpleasant were less likely to use them (p = .06).
Men who reported use of antibiotics for STD/HIV
prevention were less likely to use condoms (p = .07).
All three of the variables related to friends, condom
use and sex workers were significantly related
to condom use. If the respondent’s friends knew
about his visits to sex workers he was less likely to
use condoms p < .01). However, if the respondent’s
friends told him to use condoms or if he reported
that his friends use condoms, he was more likely to
use condoms himself p < .01).
Summary And Discussion
Results from this study have documented a number
of important findings about client behavior in Bali,
Indonesia. Clients were aware of the risks of AIDS
and other STDs, although their understanding of
transmission and prevention needs to be improved.
Condoms were used with sex workers, although
use was far from consistent. Use of condoms was
associated with age, education, migration status,
AIDS and STD knowledge, perceived susceptibility to
AIDS and STDs, positive and negative condom beliefs,
use of antibiotics and reports of friends knowledge
of visits to sex workers and condom use.
This study has several limitations. The findings of
this study are based on self-report data on sensitive
128
Furthermore, the measures related to peer influence
were also associated with use, although not always
in the same direction. If many of the client’s friends
knew about their visits to sex workers, then they
were less likely to use condoms. This suggests that
in peer groups where use of prostitutes is widely
acknowledged, risky behavior may be more common.
However, if the respondent knew that his friends used
condoms with prostitutes and if they encouraged
him to use condoms with prostitutes, he was more
likely to report condom use.
Data from the study showed that young men
(younger than age 30) were more likely than
older men to come to the brothel with friends and
to discuss AIDS with their friends. They were also
more likely to report that their friends use condoms
with prostitutes and their friends urge them to use
condoms with prostitutes. An intervention strategy
for these clients might be to recruit groups of young
men from the brothel areas and involve them in a
group intervention with their friends.
The main source of education for clients in this area
has been through media, both in the brothels and in
newspapers and television. Future programs need to
develop more focused efforts to reach clients. These
interventions may include work site interventions,
mass media campaigns, or mother models.
1. Can a person who is already infected with the
AIDS virus appear to be healthy?
2. Can a person who is already infected with the
AIDS virus but still appears healthy spread the
disease to other people?
3. Can people catch AIDS by exchanging clothes,
eating from the same dish, or shaking hands
with the person who is already infected with the
virus?
4. Can AIDS be spread through body sweat?
5. Can AIDS be spread through body contact?
6. Can an infected woman who is pregnant spread
the AIDS virus to her unborn baby?
7. Can a person catch AIDS by urinating in the same
place as a person infected with AIDS?
8. Can AIDS be spread by kissing on the mouth?
9. Can men who like to have sex with female sex
workers become infected with AIDS?
10. Can AIDS be prevented by taking medicine/
getting injections regularly?
11. Do some Indonesians already have AIDS?
12. If a condom is used during sex, can it be used to
prevent AIDS as long as it does not break?
13. Can a person who gets AIDS be cured?
14. Is AIDS always a fatal disease?
15. Are there modern medicines available to prolong
the life of someone with AIDS?
STD Knowledge
1. Can a person who is infected with a sexually
transmitted disease look healthy (without
symptoms)?
2. By always using a condom, can a person be
protected against catching these diseases?
3. Can these diseases be prevented by taking
antibiotics medicines before or after having sex?
4. Can sexually transmitted diseases be prevented or
treated by drinking jamu (traditional medicine)?
5. Can these diseases be prevented by choosing
partners carefully?
6. Supposing you had an STD, is it effective if
you treat yourself by buying medicine from a
pharmacy/drug store without seeing a doctor?
7. If a doctor gives medicine for a sexually
transmitted disease, do you have to continue the
medicine until it is finished, even if symptoms are
gone beforehand?
References
Cases of HIV/AIDS in Indonesia, June, 2001. (2001). Retrieved from
[http://www1.rad.net.id/aids/data.htm].
Fajans, P., Wirawan, D.N.,&Ford, K. (1994). STD knowledge and
behaviors among clients of female sex workers in Bali,
Indonesia. AIDS Care, 6, 459-475.
Ford, K., Wirawan, D.N.,&Fajans, P. (1994). AIDS Knowledge, Risk
Behaviors, and Condom use among Four Groups of Female
Sex workers in Bali, Indonesia. Journal of Acquired Immune
Deficiency Syndromes and Human Retrovirology, 10, 569576.
Ford, K., Wirawan, D.N.,&Fajans, P. (1998). Factors related to condom
use among four groups of prostitutes in Bali, Indonesia. AIDS
Education and Prevention, 10, 34-45.
Ford, K., Wirawan, D.N., Reed, B.D., Muliawan, P., & Sutarga, M.
(2000). AIDS and STD knowledge, condom use, and HIV/STD
infection among female sex workers in Bali, Indonesia. AIDS
Care, 12(15), 523-534.
Jones, G.W, Sulistyaningsih, E.,&Hull, T.H. (1998). Prostitution
in Indonesia. In L. Lim (Ed.), The sex sector: The economic
and social bases of prostitution in Southeast Asia Geneva,
Switzerland: International Labor Office.
Leonard, L., Ndiaye, I., Kapadia, A., Eisen, G., Diop, O., Mboup, S., &
Kanki, P. (2000). HIV Prevention among male clients of female
sex workers in Kaolack, Senegal: Results of a peer education
program. AIDS Education and Prevention, 12(1), 21-37.
Rosenstock, I.M., Strecher, V.J., & Becker, M.H. (1994). The health
belief model and HIV risk behavior change. in R.J. DiClemente
& J.L. Peterson (Eds.), Preventing AIDS: theories and methods
of behavioral interventions. New York: Plenum.
VanLandingham, M. (1995). In the company of friends: Peer
influence on male extramarital sex. Social Science and
Medicine, 47(12),1993-2011.
Wirawan, D.N., Fajans, P.,&Ford, K. (1991). AIDS and STDs: Risk
behavior patterns among female sex workers in Bali, Indonesia.
AIDS Care, 3(2), 151-164.
129
Social & Behavioral
Appendix: AIDS/STD Knowledge Questions
For Clients AIDS Knowledge
Social & Behavioral
The Smokescreen of Culture:
AIDS and the Indigenous in Papua, Indonesia
Leslie Butt1
Gerdha Numbery2
Jake Morin2
1
Department of Pacific and Asian Studies, University of Victoria, Canada.
2
Faculty of Social Science, University of Cenderawasih, Papua, Indonesia.
Pac Health Dialog. 2002 Sep;9(2):283-9
PHD Manager, Resource Books
131
Abstract
“We Papuans want to use a condom, but we don’t know how to use it, what is it used for? Now if we knew, oh a condom is used like this, this is
the way to use it, then, yes, we would like to use it.” (Simon, Awyu man)
Introduction
Throughout Asia, governments typically have reacted
to the spread of AIDS by blaming the “West,” outsiders,
or the sexual deviance of its modernizing citizenry.
In Indonesia, after years of evasion and denial, the
government seems to be moving beyond moral
judgments about sexuality towards addressing the
pragmatics of dealing with rising infection rates. In
Indonesia’s eastern most province, now known as
Papua (also known as Irian Jaya, or West Papua), all
levels of government have been galvanized as rates of
HIV infection skyrocketed in the past few years. There
are presently 20.4 cases per 100,000 people in Papua,
a dramatic contrast to the rest of Indonesia, which has
only 0.42 cases per 100,000 people1. Approximately
40% of the HIV and AIDS cases in Indonesia are located
in the province of Papua, even though that province
has less than 1% of the country’s population. If HIV is a
problem elsewhere in Indonesia, in Papua it is rapidly
becoming an epidemic.
In Papua, any prevention effort must come to
terms with an extraordinarily complex cultural and
political situation. Residents of Papua make up
two largely distinct groups Indigenous Papuans
of Melanesian descent number approximately
1.2 million, in 252 different linguistic groups.
The second group, the approximately one million
Indonesian in-migrants, are of Malay-Indonesian
descent and mostly moved to Papua from one of
Indonesia’s more populated islands after 1969, when the
province was incorporated into Indonesia. Indonesian
in-migrants dominate political and economic sectors,
as well as the military and the police. The island is
environmentally challenging, with many isolated areas
accessible only by foot or by plane. Illiteracy rates are
high among indigenous Papuans, many of whom
live in rural communities in the mountains, jungles
or along the long coastline. This paper examines the
success of AIDS educational interventions in reaching
the indigenous Papuan population in the context of
their status as a colonized people. On the basis of
research conducted in 2001 under the auspices of
Family Health International’s Aksi STOP AIDS (ASA)
campaign, we suggest intervention efforts have been
markedly unsuccessful in reaching Papuans who are
at significant risk of contracting the HIV virus.
Despite the very real logistical difficulties of
disseminating AIDS information in the province, this
paper will demonstrate that the failure of programs
to reach Papuans is due to a combination of cultural
and structural aspects of Indonesian rule in Papua.
Most project leaders and state bureaucrats are
Indonesian migrants who bring with them specific
and explicit ideas about appropriate sexuality. These
Indonesian bureaucrats generally hold an implicit,
but widespread, belief about the role of Papuan
“culture” in increasing sexual risk by promoting
risky sexual behavior. These moral judgments
about proper and improper sex assist in sustaining
inequalities in the province that are already aligned
along the lines of ethnicity. Inequitable access to
AIDS information occurs even though prevention
efforts aim to target all of the province’s inhabitants.
This paper addresses these processes by exploring
the problematic use of simplified concepts of culture
in AIDS prevention. We show how cultural values and
practices potentially become reified as the cause
of program failure, when an analysis of structural
inequities offers a more compelling explanation.
We use the sex work industry in Papua to show how
structural factors of economy and ethnicity create
conditions whereby those who use sex work services
in town and at brothels are most likely to hear about
AIDS and effective prevention. A political context of
colonial relationships, and a national political culture
which reluctantly addresses issues of sexuality, are
the reasons for a biased distribution of information
about AIDS.
133
Social & Behavioral
The Smokescreen of Culture:
AIDS and the Indigenous in Papua, Indonesia
Social & Behavioral
Culture and the Health Transition
Model
In Papua, as elsewhere, scholars and activists
seek to identify characteristics which might help
explain discrepant responses to AIDS prevention
and education. The HIV virus can potentially be
transmitted to anyone who exposes him or herself to
infected bodily fluids. But, while everyone is at risk,
patterns of infection develop along lines which are
not random. Typically, persons who engage in highrisk behaviors, such as having unprotected sex with
potentially infected partners, or sharing needles while
injecting drugs, are at higher risk than persons who
take less risks. According to the influential argument
of health transition theorists, however, there are also
behaviors rooted in cultural values which can have
a determining effect on patterns of HIV infection.
People act from a nexus of shared values and
expected behaviors, theorists argue, which can often
place a person at increased risk of contracting HIV.
The works of John Caldwell and others from the Health
Transition Centre at Australia National University
epitomize the commitment to understanding the
relationship between culture and risk1-2. Caldwell
has argued that beliefs about death, about the
merits of polygynous marriage, about early age
at marriage, and about the health-giving aspects
of sexual activity, have all affected patterns of HIV
transmission in sub-Saharan Africa. For example, in a
society which strongly values virginity, elders might
regulate sexual intercourse assiduously. In another
society, where women’s ability to reproduce is highly
valued, women might more readily engage in premarital and extra-marital sex, potentially exposing
themselves to the HIV virus. Caldwell argued strongly
for interventions to address cultural values if they
are to have an effect2. Having an “effect,” from the
perspective of health transition theory, means
changing cultural values in order to change sexual
behavior, which will in turn reduce risk of contagion.
This type of research has been widely replicated by
others elsewhere in Asia and Africa concerned to find
effective ways to modify sexual behavior4-6. However,
the issues at play in the relationship between culture
and contagion tend to get simplified to the point
where culture becomes a black box of blame for all
“deviant” behavior. During our research in Papua, for
example, many people active in AIDS work asked
me what I thought about the “culture problem” of
Papuans. There was a strong perception among
134
many of the Indonesian administrators of programs
that many Papuans were burdened by cultural values
that prevented them from learning and adhering
to safe sex principles. Polygyny; “wife swapping;”
“promiscuity;” an unwillingness to learn new ideas:
these were examples of “traditional” cultural barriers
understood to prevent Papuans from embracing
knowledge about AIDS.
Clearly there are culturally valued practices, such as
polygyny, which have the potential to increase the
risk of HIV transmission through unprotected sexual
intercourse. owever, according to a recent critique of
health transition concepts7, cultural practices such
as polygyny are too quickly labeled as “promiscuous”
and problematic, and are not as a result understood
or analyzed in context. It is one thing to say taking
on additional wives is a cultural form of promiscuous
sexuality, it is quite another to understand the
practice of polygyny from an informed viewpoint. For
example, in one Papuan society, ideas about bodily
fluids, social relationships, patterns of procreation,
and complex exchange relations are potentially all
factors affecting whether or not a man decides to
take another wife. Calling polygyny promiscuity
condenses complex sexualities at the expense of
multiple cultural interconnections. It also leaves out
the relationship between cultural practice, and the
historical, political, and economic contexts of people’s
lives. Political organizations, economic policies,
and globalization, for example, can have far more
significant effects on local patterns of HIV infection
than cultural values6. However, in most health
transition studies, culture gets essentialized as a
potent motivator which somehow incites deviation
from an abstract, but highly valorized heterosexual,
monogamous sexual norm. According to Bibeau
and Pedersen, such narrow simplifications of the
relationship between culture and risk is tantamount
to scientific racism.7 On the ground, in local AIDS
prevention efforts, culture legitimates blame, and
local cultural norms are lumped together and
made a “culture problem,” at the expense of a full
consideration not only of real-life complexities, but
also of the political and economic factors within
which societies are continually enmeshed. It is
precisely this process which we argue has occurred
in Papua. In the following section, we describe the
situation of indigenous sex workers and clients to
show how the levels of knowledge and awareness of
Papuans about condoms, AIDS and AIDS prevention
The Sex Industry in Papua
Indonesian in-migrants have dominated economic
and political institutions since the takeover of the
province by Indonesia in 1969. In the Department of
Health, and in non-profit agencies concerned with
health issues, almost all senior staff and directors
are of Indonesian heritage. This dominance of
Indonesian migrants in social and political life
remains strong, despite government efforts to
increase Papuan participation as a means to deflect
political dissent. And yet, despite the importance
of the categories of “Indonesian” and “Papuan” in
social life, all AIDS prevention efforts have been
enacted without reference to identity. In fact, most
efforts in the past decade have focused on only
two groups identified as “high risk:” sex workers
and their clients. Under the guidance of large-scale
international aid organizations, including UNAIDS,
AUSAID, and UNICEF, the provincial government
has made concentrated efforts to get sex workers
in urban centers to wear condoms, and some efforts
to get those involved on the peripheries of sex work
(brothel owners, client brokers etc.) involved in
prevention efforts as well. The sex work industry in
Papua is unique, conditioned by history and political
economies. If Papuans and Indonesians were equally
well represented in the sex-work industry in the
province, then programs would arguably reach both
groups equally. In effect, ethnic divisions, sustained
by political and economic inequities, show up in
the sex work industry as readily as they do in other
institutions in the province.
In the present, sex workers in Papua are both
Indonesian and Papuan. Sex work takes place out of
brothels, on the street, in rural makeshift locations,
and in open air locations such as on the beach or
behind buildings. Sex workers entertain clients
from all walks of life, from military leaders to dock
workers8-9.
The majority of sex workers are women (there
are also male transvestite sex workers in urban
areas, whose concerns unfortunately fall beyond
the scope of this paper10). Despite the province’s
relative isolation from urban centers, large tourist
industries, or established military bases, there are
around 4,000 regulated sex workers. There are
another 4,000 “street workers,” or sex workers who
do not operate from a fixed, known site. There are
almost certainly at least another 4,000 women who
engage in more secretive sexual exchanges in rural
locations across the province. As in many parts of
the world, few of these 12,000 women do the job
full-time. Driven by family well-being or survival
needs, many engage in the exchange of sex for cash
or goods on a temporary basis.
Sex work in Papua is highly stratified along the lines
of ethnicity. Jake Morin, one of the co-authors of this
paper, has conducted field research in many locations
across the province. Here he summarizes categories
of sex work in Papua (see Table 1).
As Table 1 shows, the ethnicity of the sex worker is
generally correlated with the amount charged for
sex. Indonesian women sex workers are most likely to
charge large amounts of money. This is not because
Indonesian women are inherently more desirable,
but because ongoing colonial relationships place
Table 1
General characteristics of the Social Structure of
commercial sex in Papua
EthnicityofofsexSex Ethnicity of Client Cost
Per
transaction
Site of Sex Work Ethnicity
Cost
per
Transaction
Work
Site of sex work
worker
Ethnicity of Client
Regulated Hostess
Bar or Hotel
Indonesian (85%)
Indonesian (80%)
Rp. 150.000 (USD $15)
Regulated Brothel
Indonesian (85%)
Indonesian (80%) Rp. 60.000 (USD $6)
135
Social & Behavioral
has less to do with cultural knowledge, than with their
structural position as an indigenous majority at the
receiving end of health care services seemingly run
primarily by, and for, Indonesian men and women.
Social & Behavioral
Unregulated Street
Dwellings
Indonesian (50%) or Papuan (60%)
Papuan (50%)
Unregulated Open
Air Street Sites
Papuan (95%)
Papuan (90%)
Indonesian women at the apex of ideas of beauty
and desire. Elite Indonesian sex workers also benefit
from a regional economy which pours vast amounts
of money into the pockets of military and business
clients, who are also almost all Indonesians, and who
prefer Indonesian sex workers.
Among the most expensive services, hostess bars
(pramuria) and state-monitored brothels (lokalisasi)
are staffed almost exclusively by Indonesian sex
workers. Bar hostesses, for example, tend to be
young and attractive women who dress in formfitting clothes as they wait for potential customers
to come to the bar. The hostess engages her client
in conversation, sits close to him, holds his hand and
generally treats him with loving care and attention.
After he has been cajoled into drinking as much as
possible (hostesses receive a percentage of beer
profits), they repair to a hotel where the hostess tries
to persuade her client to rent a room for the evening.
She may make up to Rp. 1.000.000 (about U.S. $100)
for her night’s work. She works in a controlled, fixed,
and relatively safe environment.
In stark contrast, Table 1 shows Papuan women as
more likely to be found at the lower end of the industry.
Most Papuan women do not work in brothels, but
seek sex partners at public events, through friends,
and by approaching potential clients directly. These
mostly young and attractive women have sex with
partners in a range of sites. Some locations, like
urban dwellings, are relatively secure. Others sites,
such as outside, by the side of the road or in an empty
honai (traditional hut), are far less secure. In many
cases, these exchanges fall far outside the norm of
monetized exchange with relative strangers which
provides the foundation for standard definitions of
sex work11-13. The proliferation of Papuan women
who will exchange sex for money or goods has grown
in tandem with development activities throughout
136
Rp. 50.000 (USD $5)
Rp. 25.000 (USD $2.50)
the province. A newly prosperous mining town, for
example, has become a destination for young men
who hear they can have sex without repercussions. A
research assistant described another major highlands
airfield town as “the place to go if you want to have
sex.” Places where ships dock, and where goods are
transported, attract men and women interested in
gaining from the cash economy. Rural sites where the
government has set up regional offices, and where
some Papuans receive small monthly wages, also
attract a burgeoning sex work industry. Women less
able to eke a livelihood from subsistence production
find sex work a way to supplement meager incomes.
In short, in a stratified sex industry, Papuan women
are more likely to find themselves at the bottom in
terms of income, at highest risk of personal safety,
and at highest risk of violence.
Patterns of condom use repeat the stratifications
found within the sex work industry. As Table 2 shows,
the sex workers and clients who are more likely to
use condoms are Indonesians working in brothels
and bars. This is because most condom promotions
target brothels and hostess bars as the places where
people are most likely to engage in unprotected sex
with a potentially infected partner. For example, at
one of Papua’s largest brothels located just outside
the capital city, managers have been able to convince
(almost exclusively Indonesian) sex workers to insist
on using condoms at work, and some of the women
have managed to get up to 70% of their clients to use
condoms14. But not everyone is able to afford these
elite services. Indonesian men who are financially
well-off make up the majority of clients. With their
firm hold on the military, the state bureaucracy, the
police, and the private business sector, Indonesians
are more likely to have the cash required to enjoy
the services of a bar hostess or brothel resident who
is, in turn, more likely to educate them about the
use of condoms. In contrast, the only street worker
Brothel workers and street workers have different
experiences with condoms because more effort is
expended to educating brothel patrons and brothel
semen, growth, strength, and gender, is highly
dependent on location, and is only occasionally
practiced. In another example of behavior being
used to label a tribal group, the highland Dani
have recently been described as having “free sex
parties”, “free sex” and sex that is “out of control”15.
And yet, only thirty years ago, this same group was
described as having a sexuality so muted it was
virtually absent! Clearly, categorizations about
sexuality reflect political conditions. With both the
Table 2
Condom use by sex worker worksite and ethnicity
Ethnicity of Sex
Ethnicity of
Type of Sex Work
Work
Client
Condom Use
Hostess Bar or
Hotel Worker
Indonesian (85%) Indonesian (80%)
30% - 80% condom use
Brothel Worker
Indonesian (85%) Indonesian (80%)
30% - 80% condom use
Unregulated Street
Worker
Indonesian (50%)
or
Papuan (60%)
Papuan (50%)
3% - 7% condom use
Unregulated Open
Air Worker
Papuan (95%)
2% - 5% condom use
Papuan (90%)
workers. Irrespective of the fact that some 8,000 sex
workers operate outside of brothels and bars in the
province, the 4,000 workers in brothels get priority
in interventions in part because the sexual culture
predominant in Indonesia assumes that sex workers
only operate out of known, semi-official locations.
In contrast, it is much harder to reach Papuan sex
workers who may engage in sexual relations outside
of brothels or other expected venues associated with
the formal sex work industry.
Whose Culture Problem?
To explain Papuans’ seeming reluctance to use
condoms or to practice safe sex, many Indonesian
administrators are quick to reduce complex
knowledge about Papuan sexuality to specific
behaviors. “Wife swapping,” for example, is often
described as a pervasive phenomenon throughout
the coastal Asmat tribal group. In actuality, though,
the practice is deeply rooted in complex ideas about
Asmat and the Dani, those creating the discourse
of a promiscuous sexuality rooted in cultural
practice do so in order to implement narrow
solutions which fit within the limited parameters
of health transition models of culture and sexual
risk. We suggest it is the culture of Indonesian
bureaucrats and health administrators, not that of
Papuans, which further entrenches unequal access
to information about AIDS.
In Papua, state and non-profit agency employees
work together to educate the general population
about AIDS, using a simple prevention message.
This message promotes “A” for sexual abstinence
(Abstinen), “B” for monogamy (Baku setia), and “C” for
condom (C/Kondom). However, a “culture of shame”
widespread throughout Indonesia discourages open
discussion about sexuality and foments enduring
stigmas which prevent candid public discussion about
“C”, or condoms16-17. While each public servant will
137
Social & Behavioral
intervention program in the same capital city, geared
almost exclusively towards Papuans, has a condom
use rate of less than 5%. The manager is constantly
writing letters just to try and get together enough
condoms in stock to actually be able to run the peereducator program.
Social & Behavioral
interpret ideologies personally, it remains the norm
for most Indonesian officials in Papua to be strongly
influenced by this repressive national sexual culture.
They are thus very reluctant to discuss or promote
safe sex through condom usage. For example, a huge
billboard in the province’s capital, one of less than a
half-dozen throughout the province, describes all the
ways one can get AIDS, but says not a thing about
condoms as a way to prevent contagion. On another
billboard in a highlands town, a confusing drawing
emphasizes the danger of blood transfusions, and
shows a person lying sick in a hospital bed, rather
than communicating the dangers of unprotected
sexual relations.
A bureaucratic fear of plain talk about sex means
that few Papuans possess basic knowledge of AIDS,
even though most have heard of the term. In a
standardized interview conducted with 196 Papuan
respondents in eleven different locations across the
province, 159 (81%) respondents had heard of AIDS,
but only 57 (29%) could identify a condom when
shown one. Among rural Papuans, only 8 respondents
(8% of rural respondents) could identify a condom.
Not one of the rural respondents we interviewed,
male or female, had ever used a condom, even
though there are large numbers of Papuan women
engaged in semi-commercialized sexual relations in
rural communities. Our Papuan researchers reported
that few respondents, even in cities or towns where
brothels were wellestablished, knew how to use a
condom properly or when to use one. In one rural
region, where condom use among Papuan sex
workers was less than 5%, a non-profit organization
ran a random test for HIV among100 Papuan men
who admitted to ever having sexual relations with a
sex worker. Eight out of the 100 were HIV positive8.
Indonesia’s health care system could be an effective
vehicle for AIDS education, even in hard-to-reach
rural areas. Most Papuans have experience of the
Indonesian health care and family planning program.
As Murray notes, “Indonesia has a very efficient
education, health and family planning system that
reaches down to the household level and could be
rapidly mobilized for public information and HIV
prevention…However, the Ministry of Education is
resistant to providing any form of sex education and
the ideology surrounding deviant behaviour and
public morality have prevented this from occurring so
far”17. As a result, general AIDS awareness campaigns
138
have been sporadic, mostly urban, and overall
inadequate. Since most Papuans live in rural regions
and are therefore likely only to get information about
AIDS and condoms through general promotions,
they are, again, less likely to obtain the minimum
knowledge required to give them the choice about
reducing sexual risk. If the information is presented
to them in a peremptory fashion, they are even
less interested. As one survey respondent noted,
“Papuans would be angry if shown condoms by a
rambut lurus [Indonesian]. They would say, ‘Ah, here is
another place where they are trying to push us again
into using something.’”
The combined discriminatory effect of a brothelbased condom program, an Indonesian sexual
culture of silence and shame, and a tendency to
blame Papuan culture, is particularly evident in the
following example. In the town of Merauke, site
of the highest number of HIV/AIDS cases in the
province, bar and hotel owners have been trying
to get their sex workers to remain disease-free. The
state has provided a free monthly medical checkup
for sexually transmitted diseases (STDs) for any sex
worker who shows up at the clinic. In September
2001, for example, 172 women in Merauke went
to the clinic for a free checkup. However, even
though there are approximately 400 Papuan women
involved in sex work in Merauke, in bars, on the
street, and in open-air locations, only one Papuan
woman out of several hundred patients had been to
the clinic for a free checkup in the past year. Is this
because of the “culture problem” of Papuan “shyness,”
as the clinic director charged? As he intimated, is
Papuan “tradition” too strong for women to choose
the service? Or is this because Papuan women do
not know of the service, have not received enough
information about the risks of unprotected sex, and
have not received enough training, support and
validation for promoting safe sex with their partners
and clients? Is it because the clinic office is set up in
such a way that women have to walk by a half-dozen
Indonesian administrators sitting at their desks to get
to the clinic? Is it because the doctor and attendant
nurse are not Papuan? If assisting everyone in the
province really is the aim of AIDS promotions, then
clearly the culture needing scrutiny is not so much
that of the client, but that of the organization that
imagines this structure and system to be appropriate
for all. Before the culture of Papuans can be named as
a problem, non-discriminatory fundamental access
Discussion
In the province of Papua, for individuals of any ethnic
background, rates of AIDS awareness and condom
use are unacceptably low. There are many concerned
activists from several agencies working to improve
knowledge levels. Patterns appear to be changing
under the direction of a more aggressive government
and NGO promotion campaign set in motion in 2001
by Family Health International through Aksi STOP AIDS
(ASA). ASA has increased the number of programs in
smaller, rural sites, and they are collaborating with
other institutions to get more condoms into the
province and in the hands of those who might use
them. However, condoms still remain very difficult to
locate outside of pharmacies in urban centers.
Ultimately, it is the culture of the political leaders,
and of the powerful Indonesian migrant community,
which are primarily reflected in AIDS promotions.
The free STD checkup system shows how the mostly
Indonesian officials in the health and provincial
AIDS offices initiate prevention efforts which reflect
dominant Indonesian cultural values about ways
to treat STDs. They support interventions which
validate nation-wide ideologies about prostitutes
as professional, full-time, regulated brothel and bar
workers. They are reluctant to promote condoms
aggressively throughout the province to lay
populations because dominant Indonesian values
associate condoms with shame, with professional
sex workers, and with stigma. It is convenient to seek
problems within a simplified notion of culture, and
even more convenient to propose solutions drawn
from a nation-wide strategy which ignores inequities.
Most of the time, the real effects of programs simply
go unnoticed, because in Papua officials do not use
ethnic identification in published health reports.
Statistics show a wildly successful STD checkup
program in Merauke, for example, but there are no
formal, accessible records to show that it is only
Indonesian women who go for those checkups.
If officials really were concerned about the relationship
between culture and sexual behavior, they would need
to explore specific practices at the individual tribal
level. Exchange relations, ideas of sociality, gender
norms, ideas of the body, ideas of desire and shame,
and the use of cultural sanctions against locally-coded
forms of “deviant sexuality” have all been identified as
critical factors8. They might consider how indigenous
persons can act as peer educators within specific tribal
groups and communities. They might eliminate largegroup educational seminars in favor of small, genderspecific groups, where condoms are freely passed
around and discussed. Last, they might recognize the
importance of ethnicity as a mobilizing force in the
province, and promote the use of Papuans, and of
Papuan identity, as a potential means to communicate
effectively about AIDS.
HIV/AIDS does not discriminate along the lines of
ethnicity. But in Papua, it appears likely that one
group will be more likely infected than the other.
Two unpublished reports, showing more Papuans as
HIV positive than Indonesians, may be early warnings
of what is to come8. The study of culture as relevant
only to risky behavior, as found in health transition
studies, is inadequate for understanding patterns of
infection in Papua. Factors such as limited access to
information, biased service delivery, and simplified
ideas about culture all have a significant effect on
how much Papuans hear and learn about AIDS and
safer sex.
Getting governments involved in AIDS prevention
is crucial, notes Caldwell3. But it is not enough
to scrutinize the overall commitment of national
governments to AIDS prevention. It is equally critical
to examine how that commitment gets translated into
practice on the ground. A focus on “politics” as nationwide practice, and on “culture” as localized beliefdriven
systems, leaves out the domains in the center which
are so crucial—in particular, the sexual culture of the
colonizer, and the political culture of local rule. It is in
those domains where we can come up with at least
part of the answers on how to make AIDS prevention
an effective strategy in a changing world.
Acknowledgments
We are grateful to Family Health International and
USAID for funding research on AIDS awareness and
AIDS prevention in Papua in 2001. Steve Wignall
and the Aksi STOP AIDS office in Papua provided
crucial support. The opinions expressed in this article
are those of the authors, and do not necessarily
reflect those of Family Health International or ASAIndonesia.
139
Social & Behavioral
to information, resources, and condoms must be
assured.
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Ingkokusumo, G. 2002. “Masalah HIV/AIDS sudah sangat parah
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Wambrauw, D. et al. 2001. Laporan Penelitian Perilaku
Seksualitas Wanita Jalanan di Jayapura dari AIBON hingga
HIV/AIDS [Research Report on Women Sex Workers in
Jayapura: From Glue Sniffing to HIV/AIDS]. Jayapura: Pusat
Studi Kependudukan, Universitas Cenderawasih.
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Caldwell, J. 1997. The impact of the African AIDS epidemic.
Health Transition Review, Supplement 2 to volume 7: 169-188
10. Boellstorff, T. Sex changes: Waria, transgenderism, and playing
back the Indonesian nation. Unpublished manuscript.
3.
Caldwell, J. 1999. Reasons for limited sexual behavioural
change in the sub-Saharan African AIDS epidemic. Pp. 241256 in Resistances to Behavioural Change to Reduce HIV/AIDS
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Social & Behavioral
Reasons for not Using Condoms
among Female Sex Workers
in Indonesia
Endang Basuki1
Ivan Wolffers2
Walter Devillé 3
Noni Erlaini1
Dorang Luhpuri4
Rachmat Hargono5
Nuning Maskuri6
Nyoman Suesen7
Nel van Beelen2
1
Faculty of Medicine, University of Indonesia, Jakarta, Indonesia.
2
Department of Health Care and Culture, Vrije Universiteit Medical Centre,
Amsterdam, The Netherlands.
3
NIVEL, Utrecht, The Netherlands.
4
School of Social Welfare, Bandung, Indonesia.
5
School of Public Health, Airlangga University, Surabaya, Indonesia.
6
School of Public Health, University of Indonesia.
7
Ministry of Health, Jakarta, Indonesia.
AIDS Educ Prev. 2002 Apr;14(2):102–1
141
Abstract
The aim of this study was to gather data on condom use among brothel-based female sex workers in Indonesia and to study the reasons
for not using condoms in order to provide new and existing condom promotion programs with information to improve their performance.
Quantitative data were gathered by KABP surveys (n =1450) and a condom diary with a sample of 204 female sex workers. Qualitative data
were collected by conducting focus group discussions and in-depth interviews among female sex workers and pimps. Around 53% of sexual
intercourses were reported to be protected, and12%of these protected intercourses were preceded by clients’ argumentation against it. Only
5.8% of sex workers consistently used condoms for a 2-week period of observation, and this figure decreased to 1.4% for a 4-week period.
Reasons for not using condoms from the clients’ side, as mentioned by the sex workers, were perceived less pleasure due to the condom and
the belief that clients that are acquainted with the sex workers do not need protection against sexually transmitted diseases (STDs) or AIDS.
The main reasons of female sex workers for not using condoms were the beliefs that boyfriends, native Indonesians and healthy-looking
clients cannot spread STDs. Another reason stated was that sex workers had already taken other preventive measures, like taking antibiotics.
The research also showed that pimps were not very supportive of condom use programs in Indonesia. Condom unacceptability is an important
reason for not using condoms for both clients and female sex workers, whereas pimps, who are in the best position to encourage condom
use, unfortunately consider condom use as a threat to their business. For the successful introduction of consistent condom use, it is necessary
to design interventions for both sex workers and clients and to provide appropriate educational materials and preferred brands of condoms.
Also, pimps must be involved in intervention programs.
Background
Sex Work In Indonesia
Like in other Asian countries, the sex sector in
Indonesia is quite extensive. The official number of
sex workers was 71,281 in 1994-1995 (Lim, 1998).
However, only registered sex workers have been
counted. Actual numbers must be much higher,
especially because the economic crisis that started
in 1997 led to a rise in street-based sex work when
many women were fired from their jobs and had no
other option than to turn to sex work (Rhebergen,
1999).
A wide variety of sex transactions take place, and
depending on one’s point of view, these can be
defined as sex work. Epidemiologists may define
these exchanges of sexual favours for economic
benefits as sex work; the persons involved in these
transactions, however, may not define them as such.
Like in most other countries, dominant groups in
Indonesian society define prostitution as a negative
phenomenon (Wolffers, 1997), and this adds to the
importance of the difference between self-defined
identity and the identity as defined by others. A
negative conception of prostitution is expressed
in the Indonesian word for sex worker. This is
perampuan tuna susila, meaning “woman without
morals” or pelacur, meaning a “person with incorrect
sexual behavior” (Wolffers, et al., 1999). In addition,
women who identify themselves as sex workers will
see certain relationships as sex work whereas other
relationships that are also based on an exchange of
sexual favors for economic benefits are considered
nonsex work.
Officially prostitution is not allowed in Indonesia,
and sex workers caught soliciting can be sent to
a rehabilitation camp. However, in some areas of
the big cities, brothels are tolerated. In Jakarta
prostitution is tolerated in the harbor town Tanjung
Priok. In Surabaya, the biggest port of Indonesia
and host to the Indonesian navy, toleration zones
are among others in Tambak Asri and Bangunsari.
Authorities have regulated sex work in these areas,
including health facilities, and certain restrictions
are imposed during religious events such as the
Ramadan period. Soliciting in the streets is not
allowed in Indonesia and therefore street-based sex
workers are completely dependent on the attitude of
the police toward them.
Condom Use In Commercial Sex
For the past several years AIDS prevention programs
in Indonesia have introduced the promotion of
143
Social & Behavioral
Reasons for not Using Condoms
among Female Sex Workers
in Indonesia
Social & Behavioral
condom use among sex workers and their clients,
but so far the results have rarely been evaluated
(Ford, Wirawan, Suastina, Reed, & Muliawan, 2000). It
is assumed that many factors other than knowledge
of and attitudes toward sexually transmitted diseases
(STDs) and AIDS also influence the rate of condom
use. Therefore, a more comprehensive understanding
of these factors is expected to be helpful in focusing
future programs.
Condom use is considered an effective method
to reduce STD/HIV transmission. If condoms are
to prevent effectively against HIV infection, they
must be used correctly and consistently, a position
supported by research on the effectiveness of
condoms in pregnancy prevention (Jones & Forrest,
1992; Trussel, Hatcher, Cates, Steward, & Kost, 1991).
Correct and consistent condom use is strongly
connected with human behavior: Condom strategies
rely on continuing motivation and behavior of the
condom user. To develop such strategies, data are
needed on condom use, knowledge, beliefs, practices
and behavior, and strong supportive policies are
necessary.
The 100% Condom Use Program (CUP) in
Entertainment Establishments, which was first
introduced in brothels in Thailand, has become
increasingly popular with policymakers worldwide.
It is promoted by the World Health Organization
(WHO) and other international organizations. The
main strategy of CUP is to gain the agreement of
the owners and managers of all commercial sex
establishments in a certain area to enforce condom
use as a condition of commercial sex. Sex workers are
instructed to refuse sex to any customer who refuses
to use a condom. If all sex establishments enforce
this policy, clients have no choice—they either use
condoms or they don’t have sex. The Indonesian
Ministry of Health started 100% CUPs in selected
cities some years ago, but so far, the results of these
have not been widely published (Ingshi-Mamahit,
1998).
Limited studies have been done to assess the rate of
condom use among female sex workers in Indonesia.
A research in the area of Kramat Tunggak in Jakarta
with a small sample (20 sex workers and 30 clients)
found that 64% of the clients admitted that they
never used condoms,13% claimed that they always
used condoms, and 23% that they used condoms
144
only occasionally (Mamahit, 1996). A research study
on Bali in 1991 (N = 401) revealed that in the previous
week 92% of the clients never used condoms, 6%
reported consistent condom use and 2% reported
using condoms occasionally (Fajans, Wirawan, & Ford,
1994). Data from a 1993 STD prevalence survey in
female sex workers in Surabaya suggest that during
the last paid sexual intercourse, only 14% of brothelbased, 20% of street-based, and 25% of night clubbased sex workers had used a condom. The same
study revealed that only 5% of the brothel workers
and 14% of the street workers had condoms in their
possession at the time of the interview (Joesoef
et al., 2000). These studies suggest that because
condom use with clients is low, female sex workers in
Indonesia constitute one of the communities most at
risk for HIV infection.
HIV/AIDS in Indonesia
Indonesia has a limited spread of HIV infections.
According to WHO and UNAIDS, an estimated
number of 52,000 people were living with HIV/
AIDS by the end of 1999 and an estimated number
of 3,100 people died of AIDS during 1999 (UNAIDS
and WHO, 2000). The government has calculated that
the number of reported cumulative HIV/AIDS cases
increased from 6 in 1987 to 1,956 by March 31, 2001
(Departemen Kesehatan Republik Indonesia, 2001).
By March 2001, 489 AIDS cases have been reported
and over 90% are males. Over half of the reported
cases were transmitted heterosexually and one fifth
from injection drug use.
According to UNAIDS, 0.1-0.2% of registered sex
workers in Indonesia test HIV-positive (UNAIDS
and WHO, 2000). This is confirmed by a study in
Bali, which found a percentage of 0.2% in brothelbased sex workers (Ford, Wirawan, Reed, Muliawan,
& Sutarga, 2000). Compared with other countries in
the region, this rate is quite low. However, prevalence
rates of STDs are considerably higher, which might
be an indicator for future rise in HIV. In the sample
of Balinese sex workers 60.5% tested positive for
gonorrhea, 41.4% for chlamydia and 37.7% for HPV
(Ford, Wirawan, Reed, et al., 2000).
Objectives
This study was conducted to achieve two objectives:
(a) to gather data on condom use among brothelbased sex workers and (b) to study the reasons for not
using condoms, in order to provide new and existing
Methodology
This study is part of a more comprehensive project
supported by the European Commission called
“Support for STD and HIV/AIDS Control and
Prevention Among High-Risk Populations in Jakarta,
Surabaya and Bandung” (EC no B7.5046/94/015,
1996-1997) and “Community Intervention Study
on Female Commercial Sex Workers in Surabaya,
Indonesia” (EC TS3-CT94-0332) in 1996 and 1997.
In three cities in Indonesia samples of female sex
workers in brothel areas were randomly selected to
be followed as cohorts (in Jakarta 486, in Bandung
330, and in Surabaya 634) in order to study the
factors associated with STD and HIV incidence and
with sexual (risk) behavior. In Surabaya the research
was done in the areas of Tambak Asri and Bangunsari
(total population around 1,500 sex workers), in Jakarta
in the area of Kramat Tunggak (total population
around 1,700 sex workers) and in Bandung in the
area of Saritem (total population 330 sex workers =
total-population sample).
Quantitative data were collected by conducting
KABP (knowledge, attitude, behavior, and practice)
surveys among 1,450 sex workers and condom
diaries in a subsample of 204 sex workers. The
qualitative data were collected only in Jakarta and
Surabaya by conducting 12 focus group discussions
and 24 in-depth interviews. The interviewers for the
KABP surveys were nurses who had been trained
for this purpose; the focus group discussions were
conducted by the researchers. An organization of
sex workers in Surabaya was involved in the research.
In Surabaya trained peer educators and in Jakarta
assistant researchers did condom diary data collection
and in-depth interviews on the process of condom
negotiation. This article mainly draws from the data
obtained by the condom diary study, the focus group
discussions, and the in-depth interviews.
From the total sample, 204 female sex workers (100
in Surabaya, 54 in Jakarta and 50 in Bandung) were
drawn to be followed during 4 weeks with condom
diaries in order to monitor their condom behavior
with regard to clients. These sex workers were given
a piece of printed paper once a week. They could
document their condom use on this tally sheet with
pictures—easy to use by illiterate sex workers. The
columns showed the days of the week, and the rows
featured three conditions of the condom use (without
condom, using condom without protest, and using
condom with protest). Once a week, the condom
diary data collectors visited each participating sex
worker and checked the tally sheet. The sex worker
and the data collector explored ev ery sexual contact
together to identify the client’s characteristics and
the negotiation process that took place.
Results
Background Of The Sex Workers And Their Clients
The demographic data from the KABP/cohort study
showed that 90% of the 1,450 female sex workers
came from rural areas. Their average age was 25.3
years (range = 16-44 years). On average, they enrolled
into sex work at an age of 23.5 years (range = 1544 years). Most of the women had little education.
About 80% had been to primary school for 6 years
or less, about 10% had more education, and another
10% had no schooling at all. The sex workers were
very mobile. The largest number of women (80%)
reported that they had been living in their brothel for
less than 1 year. Only 4% resided there for more than
2 years. Most sex workers said they were widows,
only one was married, and approximately 12% said
they had never been married before. About 18% of
the women claimed that they had at least one steady
boyfriend.
TABLE 1. Characteristics of 5,603 Sexual Contacts by 204 Sex Workers
Ethnic background
n
%
Native Indonesian
4,292
76.6
Chinese origin
1,299
23.2
12
0.2
Foreigner
Client relationship
n
%
New
3,256
58.1
Regular
2,216
39.6
131
2.3
Boyfriend
145
Social & Behavioral
condom promotion programs with information to
improve their performance. This article examines the
results of quantitative and qualitative research into
the issue of condom use among female sex workers
in Indonesia and into the reasons why they do not
use condoms consistently. Based on these results,
recommendations are formulated for staff of condom
promotion programs in Indonesia.
Social & Behavioral
Knowledge of STDS/AIDS
Condom Negotiation
The KABP study showed that approximately three
fourths of sex workers had ever heard of STDs
(74.8%). Moreover, 60.5% of sex workers mentioned
that sexual intercourse is the most important method
of HIV transmission whereas only 14% mentioned
injections. When the women were asked what kind
of diseases they feared most, a large majority (78.8%)
mentioned AIDS, 8% mentioned gonorrhoea or
syphilis, and a very small percentage said that they
were not afraid of any single disease.
The condom diary study recorded the condom
negotiation process of each sexual contact during a
4-week period. Characteristics of sexual partners, such
as rate of acquaintance (new client, regular client,
boyfriend) and ethnic background of the clients were
also recorded, to see if there was any difference in
behavior toward certain kinds of clients.
Condom Use Prevalence
The 4-week condom diary study, which involved 204
female sex workers, recorded altogether 730 personweeks and showed a recording of 5,603 sexual
intercourses or around 8 intercourses per sex worker
per week. From the total of 5,603 intercourses, 76.6%
were with native Indonesian clients, 23.19% were with
Indonesians of Chinese origin (who are considered
foreigners) and the rest were intercourses with “real”
foreigners. Most of sexual contacts were with new
clients (58.1%), 39.6% with regular clients and the
rest (2.3%) with boyfriends (Table 1).
Condom use with boyfriends (34%; 95% CI = 2542%) was significantly less common than condom
use with clients (53%; 95% CI = 51-54%). There was
no significant difference in condom use with regular
or with new clients (52.67 vs. 53.83%) (Table 2).
Table 2 also suggests that ethnic Chinese customers
and foreigners use condoms slightly more than
Indonesian customers.
Consistent Condom Use
Although a small majority (2,952/5,603; 53%) of
sexual contacts between sex workers and their clients
were protected, there were only 12 sex workers
(5.9%) who consistently used condoms in the 2-week
period of observation, and only three (1.5%) in the
4-week period. Also, 13 sex workers (6.4%) did not
use condoms at all in the 2-week period, and 3 (1.5%)
in the 4-week period (Table 3).
In 32.4% (955/2,952) of the protected intercourses,
the condom use was initiated by the sex workers,
in 21.8% (643/2,952) of the cases by the clients and
in 45.9% (1,354/2,952) of the cases by both of them
(Table 4).
If we look at condom offer in protected intercourses,
we see that the offer had to come from the sex workers
in case the contact was a new client or a boyfriend.
Regular clients themselves proposed the use of a
condom in 80% of their protected contacts. In cases
in which the sex workers offered to use a condom,
12% (115/955) of the clients protested first but finally
agreed to use one. However, with boyfriends in 11 of
the 25 (44%) protected contacts, their partner
accepted only after being seduced. Sex workers
had to offer condoms significantly less to clients of
Chinese origin (22.7%), as they themselves usually
brought the condoms along (see Table 4).
Condom Availability
In almost 80% of the cases, the condom was brought
by the customer or was bought by the customer or
the sex worker just prior to the sexual contact (Table
5). It is very rare that sex workers have condoms
available before a client arrives, but on the other
hand about 17% of the condoms used were provided
by the brothel.
Unprotected Intercourses
In about 87% of the unprotected intercourses, the sex
workers made a condom offer and tried to persuade
the client to use a condom. However, in about half of
the cases (49.7%), the women gave up immediately
TABLE 2. Type of 5,603 Sexual Contacts and Condom Use by 204 Sex Workers
Ethnic background
Native Indonesian
Chinese origin
Foreigner
146
n
%
2,165
50.4
Client relationship
n
%
New
1,714
52.7
1,194
53.8
44
33.6
779
60.0
Regular
8
66.7
Boyfriend
Condom use
2 Weeks
%
4 Weeks
%
12
5.9
3
1.5
179
87.8
198
97.1
13
6.4
3
1.5
Consistent
Nonconsistent
None
TABLE 4. Condom Offer Preceding Protected Intercourses by Client Characteristics
Condom Offer
Sex worker
Client
Both
n
%
n
%
n
%
Native Indonesian
775
35.8
492
22.7
898
41.5
Chinese origin
177
22.7
146
18.7
456
58.5
3
37.5
5
62.5
0
0
New
691
40.3
393
22.9
630
36.8
Regular
239
20.0
233
19.5
722
60.5
25
56.8
17
28.6
2
4.5
Ethnic background
Foreigner
Client relationship
Boyfriend
The qualitative research, consisting of focus group
discussions and in-depth interviews, revealed the
reasons why sex workers do not use condoms or give
up their condom negotiation after the client refuses.
Because no clients were interviewed, the information
on the clients’ views are the perspectives of the
women.
condoms feel slippery and cold. The second reason
for refusal is that clients think they do not need
protection because they are acquainted with the
women. Arguments frequently given by regular
clients are: “Why should I use a condom? You are just
like my wife” or “I am your regular client; why should
I use a condom?” In this situation, sex workers will
stop their negotiations at an early stage, although
the quantitative data showed that in 41% of the
unprotected intercourses with regular clients, sex
workers tried to seduce clients into using a condom
(see Table 6). On the other hand, it was also noted by
sex workers that if a regular client or a boyfriend saw
another client coming out of the room of his favorite
girl or his girlfriend, he would ask for a condom. The
third reason for refusal is that clients usually consider
themselves healthy persons, who are free of diseases.
If a sex worker insists on using a condom, some clients
wonder if she herselfhas a disease. There are even
clients who say that the most important preventive
measure is their cleanliness. Usually they promise
to take a bath first. Also, some clients do not accept
using a condom because they state they have taken
antibiotics preventively. Some of them even bring
these antibiotics to share them with the women.
Clients’ Views. As mentioned by the women, clients
refuse to use condoms because most of them
claim they cannot enjoy the sexual intercourse, as
Sometimes clients refuse to use condoms, saying
that the sexual intercourse will not last long. In this
case some women would stop arguing with them,
after the client refused and in 37.2% of the cases after
some persuasion was used (Table 6). The sex workers
were significantly more likely not to offer a condom
at all to regular clients than they were to new clients
(19% vs. 4.6% of unprotected intercourses). And,
not surprisingly, in 93.1% of the unprotected sexual
intercourses with boyfriends, the women did not
discuss condom use.
Sex workers were also less likely to give up the
condom negotiation if the client was of ethnic
Chinese background. In 70% of the unprotected
sexual contacts with Chinese clients, the sex worker
tried to seduce or persuade the client to use a
condom compared with about 30% of the contacts
with native Indonesians (see Table 6).
Reasons For Not Using Condoms
147
Social & Behavioral
TABLE 3. Consistent Condom Use During Two and Four Weeks, Registered by Condom Diaries
(N Sex Workers = 204)
TABLE 5. Condom Source
Social & Behavioral
Protected Intercourses
Condom Source
Client brought the condom
n
%
1,414
47.9
946
32.0
Client or sex worker bought before sexual contact
Available in brothel, bought by sex worker
Available, provided by brothel
Available, sex worker got from previous client
97
3.3
493
16.7
2
0.1
TABLE 6. Condom Negotiation Process Preceding Unprotected Intercourses by Client Characteristics
Negotiation Process
Offer Only
Offer and Seduction
No Offer
n
%
n
%
n
%
New
908
58.9
563
36.5
71
4.6
Regular
407
39.8
421
41.2
194
19.0
3
3.5
3
3.5
81
93.1
1198
56.3
623
29.3
306
14.4
116
22.3
364
70.0
40
7.7
4
100.0
0
0
0
0
Client relationship
Boyfriend
Ethnic background
Native Indonesian
Chinese origin
Foreigner
because both clients and sex workers believe that
brief sexual contacts reduce or prevent the risk of
contracting STDs. Another reason for non-condom
use is that some clients refuse the condoms provided
for free by prevention programs, because these are
considered uncomfortable.
Sex Workers’ Views. In general, the sex workers accept
the importance of condom use to prevent STDs.
They also state that condoms give them a feeling of
cleanliness, for they do not need to wash their vagina
after the intercourse. One sex worker interviewed
said: “I like using condoms, because it maintains our
cleanliness. If I use a condom I feel clean and good.”
Nevertheless, most of the sex workers used partly the
same arguments against condom use as their clients.
They claimed that they do not offer condoms to some
of the men they have sexual contact with, because
they are acquaintances: boyfriends, close friends, or
regular clients. The quantiative study confirms that in
19% of all unprotected sexual contacts with regular
clients, the sex workers did not offer a condom
compared with 4.6% of contacts with new clients (see
Table 6). The female sex workers said that they had
148
experienced unprotected sex before with those men
at least once and had no proof of any single disease
they got from them. One woman said: “Well, if I know
the client, I would not use a condom, but with a new
client I would ask him to use one.” Another shared: “If
I have sex with my boyfriend, we don’t use condoms
because we have already proven our cleanliness.”
The finding that condoms are offered depending on
the kind of sexual partner is validated by the condom
diary study. The quantitative data confirm that
female sex workers make less of an effort in offering
condoms to regular clients and boyfriends than to
new clients (see Table 6; p< .001). On the other hand,
there is no significant difference regarding condom
use between new and regular clients, as compared
with boyfriends (see Table 2). Regular clients with
whom condoms are used seem to be genuinely
motivated as 80% of them agree to use condoms
without negotiating (see Table 4). Most female sex
workers believe that fellow countrymen cannot
infect them, which is another reason for not offering
condoms. As shown by the KABP data, more than half
of the women (58%) think that they run the biggest
risk of getting HIV when they have sexual contact
Interviewer: What is your opinion, are STDs preventable?
herbs, or she tries to persuade him to use a condom.
Another option is to simply abort the transaction by
telling him that she suddenly has got her period. If
the body of the client looks dirty, the sex worker will
ask him to take a bath first.
Sex Worker: Yes, they are. We have condoms. If we have
sex with foreigners we can usecondoms.
During a focus group discussion one of the women
told that she hardly ever uses condoms, because she
never has sex with foreigners. Another sex worker
explained why she and her friends were reluctant
to serve foreigners: “They eat different food, so their
sweat is different. That is why we are afraid to have
sex with them.” This reflects the believe that HIV
infection is alien, foreign, and cannot come from
someone close, who was born on the same soil, eats
the same food, and produces the same sweat. As a
consequence of this belief, female sex workers easily
agree not to use condoms if native clients ask them
to do so.
Condom diary quantitative data (see Table 2)
confirm that Chinese Indonesians and foreigners
are more likely to use condoms, compared to native
Indonesians (p< .001).
Some of the female sex workers do not offer condoms
if the client’s body looks clean or if the client looks
healthy. They think the body’s and genital organs’
cleanliness is a reflection of someone’s health. One
sex worker noted: “Even though I amnot pretty
myself, if I find the client is dirty, I do not want to
serve him, I’d better serve an ugly guy who is clean,
whose body looks clean.” Another sex worker added:
“Well, his organ should be clean; if there are red spots
on it, he suffers from the disease.”
According to the sex workers, a healthy client is a
man who is not skinny and who walks steadily: “If
somebody is sick, I can detect this from the way he
walks. He staggers like that,” said one of them. Another
woman said: “Yes, a sick person is usually very skinny,
but it is not ordinary skinny; it is different.”
In general, a sex worker will check her client by
looking at his body cleanliness. If he looks clean, she
will check his genitals by touching and squeezing the
penis. If it feels hot or produces a creamy or purulent
discharge, she asks the client to wash his penis (with
cleansing agent) and take antibiotics or traditional
Female sex workers also do not like to use condoms
if they make love with their boyfriends because they
believe that condoms reduce sexual pleasure. One
woman said: “Using a condom is not enjoyable. With
a new client I use a condom, but with my boyfriend
not.”When the researchers asked sex workers whether
they are afraid of getting STDs/AIDS, one of them
replied: “No, I am not. I just keep my body healthy.”
Then she added: “Well, if it is a regular client, nothing
can happen.” Other women do not offer condoms to
their clients due to other reasons, such as pain during
intercourse, condoms being slippery, and the idea
that condoms would make the sexual intercourse
last longer, which in turn would produce pain and a
waste of their time.
Another reason for not suggesting condom use was
the fear that the client would walk away and go to
another sex worker, because competition among
sex workers is high. Finally, some women stated that
they do not use condoms because their clients do
not ask for them. As we have seen before, in 13% of
the unprotected sexual intercourses, the sex workers
had a passive attitude and did not offer condoms
at all to their clients (see Table 6). Some of them felt
embarrassed to talk about condoms.
If we categorize these arguments against condom
use, they can be divided into reasons pertaining to
characteristics of clients (looking clean or healthy,
being regulars, boyfriends or fellow countrymen,
etc.) and reasons pertaining to characteristics of
condoms (reducing sexual pleasure, causing pain or
embarrassment, etc.).
No Negotiation. We also tried to understand why
female sex workers did not try to persuade clients
to use condoms. As mentioned before, in half of
the unprotected intercourses, the sex workers took
no further action to persuade clients if they refused
after the first offer. Their main reasons for stopping
condom negotiation were the same as the reasons
for not using condoms. They were afraid of losing
clients, they presumed that their regular clients are
free of STDs, and they presumed that clients who
149
Social & Behavioral
with foreign clients. In fact, they treat foreigners
differently, as shown in the following excerpt of an
in-depth interview:
Social & Behavioral
looked clean from the outside are not considered
contagious. Another reason mentioned by sex
workers for not persuading clients is that they had
tried to convince their regular clients several times
before, but it did not work. Therefore, they considered
persuading clients to use a condom a waste of time.
Environmental Factors. Besides social and cultural
factors, the situation before or during the transaction
can influence the use of condoms. Before the
transaction, both clients and female sex workers
usually drink beer. This affects the ability of the
women to control themselves, which in turn could
reduce their willingness to offer condoms.
Another factor is the availability of condoms. Despite
the willingness of the government to provide condoms,
in fact not all women have enough condoms on hand,
and late in the evening when they need them most,
they are difficult to get (see Table 5). Not many brothels
provide condoms, so if the clients do not bring them,
the sex workers must buy them themselves or ask the
servant to buy some from the stalls located outside the
brothel. Condoms are not very expensive, from Rp 250
up to Rp 2,500, compared to the price of Rp 20,00050,000 for a sexual contact (Rp 10,000 = U.S. $0.40).
The cost of condoms is therefore not a reason for not
offering them. Nevertheless, the quantitative study
showed that in almost half of the protected sexual
intercourses (47.9%), the condom was brought by the
client, whereas in only 3% of the cases the condom
was purchased by the sex workers prior to the client’s
visit.
The most commonly used and most preferred
condom brand is Young-young (70%), followed
by Banjaran (15%), and Simplex (6%). Other
brands are Superlong, Kondom 25, and Durex. In
general, the sex workers prefer condoms bought
by the clients because these are thinner and look
nicer than Banjaran condoms, which are provided
by the Social Welfare Provincial Office for free.
Moreover, they said that when a client uses his
own condom its color resembles the color of the
client’s penis, which is preferred. As mentioned
before, clients also often refuse to use condoms
that are distributed by the local health office or
nongovernment organizations (NGOs).
Almost all female sex workers and pimps are familiar
150
with condoms, even though during the focus group
discussions it was noted that some of them had not seen
a condom at all or never used one before. In general,
they comprehend the function of condoms either for
the prevention of STDs or pregnancy. Although most
of the pimps said that they always encourage sex
workers to use condoms and to have them at hand all
the time, in fact there was no evidence of real activities
on the part of the pimps to support the condom use
programs of the government and NGOs. Usually they
did not urge sex workers to negotiate condom use, as
stated in the following excerpts: “Well . . . it depends on
her [the sex worker] . . . the one who will do the job. . . .
It is difficult to get money nowadays. . . why should she
refuse clients?” Pimps said that they provide condoms
in their brothels, but when they were asked about the
condom supply they replied: “They [the sex workers]
know about the condom supply. . . . I guess they buy
them at the stalls.” Another pimp said: “If we run out
of condoms, they [sex workers] will buy them at the
stalls.” These sentences reflect that in reality pimps do
not much to protect the women from STDs/AIDS. The
quantitative study confirmed that in only 16.7% of the
protected intercourses, the condom has been made
available by the brothel (see Table 5).
Condom Negotiation Strategies
During focus group discussions, it was noted that
some of the female sex workers were successful in
persuading clients by using specific strategies, such
as trying to frighten them. One sex worker shared
that she usually told her clients the following:
“Frankly speaking I do not only serve you. Before you
came . . . somebody else was with me. . . . And you
never know whether I am healthy or not.” She added,
“Usually my clients were afraid.”
Another sex
argumentation:
worker
used
the
following
“I say: ‘If you get sick, won’t you feel sorry that your
wife will get that disease too from you? And if your
wife is pregnant your baby also will get sick. Think
about it.’”
Yet another woman said: “I use humor . . .like this . . .:
‘Why don’t you use a parachute?’ Usually the client
will reply: ‘Why, do we want to fly?’ I’d say: ‘Yes, and
we can fly more freely.’ Then they will agree but want
me to get the condom.”
Discussion
Limitations Of The Study
The first weakness of the condom diary study is that
because part of the female sex workers did not fill out
or forgot to fill out the tally sheet, the data collector
had to ask them about their sexual activities during
the last 7 days. This may induce a bias, because some
intercourses may have been forgotten. However, this
bias probably is small because the period of recall was
only 1 week and the number of contacts on an average
(eight per week) was limited. Another weakness
was that the data collectors for the condom diaries
consisted of two kinds of personnel: peer educators
and assistants to the researchers. Even though these
two groups had had a similar training, bias still might
exist. Because peer educators resemble the people
they interview more, their report may be more valid
because of a trustful relationship between interviewer
and interviewee. On the other hand, they might
have given a more favorable picture of the situation
than it in reality is. The third weakness was the lack
of validation of condomuse. Validation of condom
use is of high priority and fraught with difficulties.
Research conducted in Kramat Tunggak in 1996 tried
to do condom use validation by comparing condom
use as recorded by sex workers with the number
of used condoms (Mamahit, 1996). But that kind of
validation also creates negative effects because it
can be seen as a form of control, and the female sex
workers might try to conceal the number of sexual
intercourses without condoms.
Trends In Condom Use
Because data on condom use among female sex
workers in Java are hardly available, it is difficult to
recognize trends in condom use. In our study, an
overall percentage of 53% condom use was found.
In the 1993 Surabaya survey mentioned in the
introduction, percentages varied between 14% and
25% for condom use during the last paid sexual
intercourse (Joesoef et al., 2000). Although this
suggests an increase in condom use, the outcomes
of this study and ours cannot easily be compared.
Ongoing research in Bali revealed that knowledge
of AIDS and awareness of STDs has increased
tremendously in the study population since
1992. Reported condom use has also increased
substantially (to an overall 69.9% in 1998). Data for
this study were drawn from cross-sectional surveys
of female sex workers conducted in 1992, 1994, and
1997 to 1998 (Ford, Wirawan, Reed, et al., 2000).
The same researchers found that condom use with
clients varied widely by group. Women in low-price
brothels reported the lowest levels of use (19% of
encounters in the previous week), with women
from the mid- and high-price groups reporting
higher levels (68-71%) and women working in the
tourist areas reporting the highest levels of use
(90%) (Ford, Wirawan, & Fajans, 1995).
If we look at the consistency of condom use, the
figures are very low. In fact, our research showed
lower condom use consistency for both groups
as compared to other investigations in Kramat
Tunggak a year earlier. That research, with a small
sample (N = 20), showed that during a 2-week
condom diary study 35% of female sex workers
always used condoms and 45% never used them
(Mamahit, 1996). In our research, the sample was
considerably bigger, and there was more variation
because three cities were involved. However, the
percentages were much lower (5.8% consistently
used condoms and 6.4% did not use them at all).
Another reason for the differences might be the
different data collection procedure. The Kramat
Tunggak research in 1996 did a validation of the
condom use by asking the participants to collect
each used condom into a wrapper. The researcher
checked the condom diary with the condom
wrappers. Of the clients (N = 30) in that study 13%
admitted that they always used condoms, 64%
never used condoms, and 23% used condoms
occasionally. In comparison, the 1991 Bali research
on clients (N = 401) mentioned earlier revealed that
in the previous week 6% of the clients reported
consistent condom use with sex workers where as
2% reported using condoms occasionally and 92%
reported no condom use at all (Fajans et al., 1994).
These two studies support our conclusion that
the consistency of condom use in Indonesia is still
relatively low.
151
Social & Behavioral
Some sex workers will try to seduce the client by
giving a special foreplay. One said: “If there is a client
who doesn’t want to use a condom, I seduce him,
I kiss him again and again. Usually it works and he
agrees to use one.”
Social & Behavioral
Reasons for Not Using Condoms
Although female sex workers understand that they
are susceptible to STDs/AIDS and they are afraid of
contracting these diseases, in fact they fail to ask
or persuade clients to use condoms. Even though
most of them try to suggest condom use and even
try to persuade their clients to use one, only half of
the sexual intercourses are actually protected. These
data lead to the assumption that the sexual partners
of the women seem to play a big role in the decision
whether or not a condom is used. Future research
should therefore be directed at the behavior of the
clients and the boyfriends.
Research in developed countries showed that many
sex workers insist that their paying clients use a
condom but not their non paying sexual partners.
For example, female sex workers in Copenhagen
used condoms much more consistently for vaginal
intercourse with clients (94.5%) than with casual
(24.5%) or regular (9.2%) nonpaying sexual partners
(Alary, Worn, & Kvinesdal, 1994). Another research
study in Long Beach, California, showed similar
findings: 68.9% of sex workers reported that they
never used condoms with their boyfriends, and 13.6%
never used condoms with their paying clients (N=
273) (Corby&Wolitski, 1992). Our study indicates that
condom use with boyfriends was only 34% compared
to an overall condom use of 53%. As our data show,
the sex workers explained their lack of condom use
in personal relations to a perceived reduced sexual
pleasure.
There are several myths among female sex workers
with regard to condom use and STDs/AIDS. These
can be categorized in four major areas: illness,
cleanliness, food and sweat, and acquaintance. The
first area concerns myths about STD illnesses. The
female sex workers perceive a person who has an STD
as someone who staggers, is “extraordinary skinny”
and has spots over his body. The second area, myths
about cleanliness, has a close relationship with the
illness myths. A client who has a clean body or clean
penis is considered a healthy person. The third myth
involves food and sweat. According to the female
sex workers, foreigners eat different food, so they
produce different sweat. This sweat, they believe, is
more infectious than the sweat of fellow countrymen
and can cause diseases like STDs and AIDS. Therefore,
foreigners, including Indonesians of Chinese origin,
152
are considered more contagious than native
Indonesians. The fourth myth is the acquaintance
myth. Clients who come for the second time are
already considered as regular customers or friends.
With these regular clients, the use of condoms is not
so strongly pursued as during the first visit, because
female sex workers think that these clients are
free of diseases, as proved by the previous sexual
intercourse.
As a consequence of these myths and beliefs, a
client who is not skinny, has a clean body, is a native
Indonesian, and who has visited the sex worker
before very likely will not use a condom because the
sex worker will not offer him one nor persuade him
to use one.
From the focus group discussions and in-depth
interviews it showed that the vast majority of female
sex workers try to prevent STDs/AIDS by taking
special actions regularly before and/or after the
sexual intercourse. These strong beliefs decrease
their motivation to offer and convince clients to use
condoms. Their preventive actions include taking
antibiotics or traditional herbs, washing the clients’
and their own genitals with a cleansing agent, and
inspecting the clients’ genital organs.
Environmental factors also coincide with condom
use. Usually female sex workers are asked to join a
client to consume alcoholic drinks. This situation
makes them unable to control themselves, so they
fail to persuade clients to use a condom. Another
influencing factor is the availability and acceptability
of condoms. In general, the availability of condoms is
good. Female sex workers can buy them at the stalls
outside the brothel or sometimes in the brothel, and
they are provided for free by the government and
several NGOs. A big problem is that the sex workers
usually do not have them at hand (they were available
only in 20% of the cases). The sex workers expect the
clients to bring them, or they or the clients buy them
just prior to the sexual intercourse.
Most sex workers accept condom use; only very few
women did not like to use condoms at all. The pimps
said that they always ask their women to ask clients
to use condoms, but if the clients refuse, it is up to
the sex worker whether she wants to continue the
transaction or not. Overall, pimps are very aware
Implications For Condom Promotion Programs
Unfortunately, these values, myths, beliefs, attitudes,
and environmental factors are not addressed
appropriately by most HIV prevention programs
among female sex workers in Indonesia. In the
framework of the research program, analysis of
several leaflets and brochures developed by the
Ministry of Health or NGOs showed that no material
has covered these issues. If behavioral change such
as condom use is expected to be increased, then it is
time to cover all those issues in the development of
health educational materials.
An important factor that needs to be noted by
prevention programs is condom availability,
which must be addressed both by increasing the
accessibility of condoms and by increasing their
acceptability. As sex workers are not the only ones
responsible for condom use, pimps and brothel
owners should be educated. Locally adapted 100%
CUPs could be developed and tested in brothel areas
with the cooperation of brothel owners. Also pimps
could have an active role in promoting condom use;
therefore an intervention to promote condom use
should cover this group.
Many female sex workers do not try to suggest
condom use to their regular clients because they are
afraid of being refused. On the other hand, this study
showed that in Jakarta and Surabaya more than 30%
of protected sexual intercourses are precededy the
client’s refusal and 42% of boyfriends protested first
but then agreed to use a condom. The implication of
these findings is that it is worthwhile to encourage
female sex workers to offer and persuade their
sexual partners, including their boyfriends, to use a
condom. Unfortunately, because their knowledge of
STD/AIDS is not supported by the skills to negotiate
with the clients, many women abort the negotiation
process when their sexual partners refuse to use
condoms. However, during focus group discussions
it was noted that some of the sex workers succeed
in persuading clients by using specific strategies.
These strategies can be observed, developed and
finally used in training of female sex workers how
to negotiate condom use with their clients. This
was also suggested by researchers from Bali (Fajans,
Ford, & Wirawan, 1995). Skills-training and roleplaying exercises may be especially useful in this
regard (Rosenberg&Weiner, 1988). Also, the positive
aspect of condom use many sex workers expressed
(condoms giving them a feeling of cleanliness) could
be stressed in educational sessions and materials.
References
Alary, M., Worn, A. M., & Kvinesdal, B. (1994). Risk behavior for HIV
infection and sexually transmitted diseases among female sex
workers from Copenhagen. International Journal of STD and
AIDS, 5, 565-367.
Corby, N. H., & Wolitski, R. J. (1992, July). Relationship between street
sex workers’ attitudes and condom use by type of partner.
Paper presented at the Eighth International Conference on
AIDS/III STD World Congress, Amsterdam.
Departemen Kesehatan Republik Indonesia, Direktorat Jendral PPM
(Directorate General Communicable Diseases&Environmental
Health, Department of Health) (2001). Available at http://
www.depkes.go.id/Ind/ News/HIV-aids/DATA/2001/meii.htm
Fajans, P., Ford, K., & Wirawan, D. N. (1995). AIDS knowledge and
risk behaviors among domestic clients of female sex workers
in Bali, Indonesia. Social Science & Medicine, 41, 409-417.
Fajans, P., Wirawan, D. N.,&Ford, K. (1994). STD knowledge and
behaviors among clients of female sex workers in Bali,
Indonesia. AIDS Care, 6(4), 459-475.
Ford, K., Wirawan, D. N., & Fajans, P. (1995). AIDS knowledge, risk
behaviors, and condom use among four groups of female
sex workers in Bali, Indonesia. Journal of Acquired Immune
Deficiency Syndrome and Human Retrovirology, 10(5), 569576.
Ford, K., Wirawan, D. N., Reed, B. D., Muliawan, P., & Sutarga, M.
(2000). AIDS and STD knowledge, condom use and HIV/STD
infection among female sex workers in Bali, Indonesia. AIDS
Care, 12(5), 523-435.
Ford, K., Wirawan, D. N., Suastina, S. S., Reed, B. D., & Muliawan, P.
(2000). Evaluation of a peer education program for female sex
workers in Bali, Indonesia. International Journal of STD and
AIDS 11(11), 731-733.
Ingshi-Mamahit, E. S. (1998). 100% condom policy in brothel
complexes in Indonesia: Lessons learned from Kramat
Tunggak Study [Abstract No. 43268]. International Conference
on AIDS, Geneva.
Joesoef, M. R., Kio, D., Linnan, M., Kamboji, A., Barakbah, Y.,&Idajadi,
A. (2000). Determinants of condom use in female sex workers
in Surabaya, Indonesia. International Journal of STD and AIDS,
11(4), 262-265.
Jones, E. F., & Forrest, J. D. (1992). Contraceptive failure rates based
on the 1988 NSFG. Family Planning Perspectives, 24, 12-19.
Lim, L. L. (1998). The sex sector: The economic and social bases of
prostitution in Southeast Asia. Geneva: International Labour
Office.
Mamahit, E. (1996). Determinants of the STD/AIDS-related behaviors
of female commercial sex workers in Kramat Tunggak, Jakarta,
Indonesia. Unpublished master’s thesis, Boston.
Rhebergen, D. (1999). Anak-anak Jalan Diponegoro. Female
street sex workers in Surabaya, Indonesia. Amsterdam: Vrije
Universiteit.
Rosenberg, M. J. & Weiner, J. M. (1988). Prostitutes and AIDS:
A health department priority? American Journal of Public
Health, 8(4), 418-422.
153
Social & Behavioral
of the importance of using condoms, but probably
because of self-interest, they do not push their sex
workers to ask clients to use a condom.
Social & Behavioral
Trussel, J., Hatcher, R. A., Cates, W., Steward, F. H.,&Kost, K. (1991).
Contraceptive failure in the United States: an update. Studies
in Family Planning, 21, 51-54.
UNAIDS and World Health Organization (2000). Epidemiological
Fact Sheet on HIV/AIDS and sexually transmitted diseases,
Indonesia. Geneva: Author.
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Wolffers, I., Triyoga, R. S., Basuki, E., Yudhi, D., Devillé, W., & Hargono,
R. (1999). Pacar and Tamu: Indonesian women sex workers’
relationships with men. Culture, Health and Sexuality, 1(1),
39-53.
Wolffers, I. (1997). Culture, media, and HIV/AIDS in Asia. Lancet,
349(9044), 52-54.
A. Sugihantono, MD1
M. Slidell, BA2
A. Syaifudin, SKM, DAPE1
H. Pratjojo, SKM1
I.M. Utami1
T. Sadjimin, MD, PhD3
Kenneth H. Mayer, MD2,4
1
Provincial Health Services, Central Java Province, Republic of Indonesia.
2
Brown Medical School, Providence, Rhode Island.
3
Faculty of Medicine, Gadjah Mada University, Clinical Epidemiology and
Biostatistics Unit, Dr. Sardjito General Hospital, Yogyakarta, Republic of
Indonesia.
4
The Miriam Hospital, Providence, Rhode Island.
AIDS Patient Care STDS. 2003 Nov;17(11):595-600
Mary Ann Liebert, Inc.
155
Social & Behavioral
Syphilis and HIV Prevalence among Commercial
Sex Workers in Central Java, Indonesia:
Risk-Taking Behavior and Attitudes that May
Potentiate a Wider Epidemic
Abstract
The A cross-sectional study was conducted on 200 commercial sex workers (CSWs) from two brothel communities in Central Java, Indonesia, to
determine the seroprevalence of syphilis and HIV and characterize associated knowledge, beliefs, and risk-taking behaviors. A questionnaire was
administered and blood drawn for HIV and syphilis serologies. Focus groups with a total of 20 women were also conducted at both communities
to supplement survey data. The mean CSW age was 27.3 years; mean number of clients seen per day was 2.27. The prevalence of syphilis and HIV
were 7.5% and 0.5%, respectively. Thirty percent said they and their partners never used condoms during sex, and only 3.0% said they always
used condoms. The most common client groups were truck drivers and sailors. While Central Java appears to remain in a pre-epidemic state, there
is enormous potential for a significant increase in HIV and STD transmission.
Introduction
There is great disparity between the United Na ions’
seroprevalence estimates of HIV in Indonesia and
the number of reported cases. The United Nations
estimates that 120,000 adults and children, or 0.1%
of the Indonesian population were infected with HIV
at the end of 2001.1 The actual number of recorded
cases is far lower. From April 1987 through the end of
2000, there had been 1624 HIV/AIDS cases reported
in Indonesia.2 Of these, 1172 were HIV infections
(403 new cases in 2000) and 452 cases of AIDS (178
new cases in 2000).2 Infections with HIV and AIDS
have been reported in 23 of the 26 provinces.2
The island of Java is home to 647 people with HIV
and 288 with AIDS.2 In Java there have been 116
deaths attributed to the complications of HIV/AIDS.2
The vast majority of HIV/AIDS cases in Java (36.1%)
are from the special province of Jakarta whereas
only 1.6% of re ported cases are from the province of
Central Java.2
The province of Central Java (population 31 million3)
was one of the first Indonesian provinces to document
the presence of HIV with the first case recorded in
April of 1994.2 Yet the documented prevalence of
HIV/AIDS in the province remains very low with only
0.1 HIV/AIDS cases per 100,000 people.2 At 0.02 cases
per 100,000 the prevalence of AIDS in Central Java
is 10 times less than the national prevalence of 0.2
cases per 100,000.2 By the end of 2000 there were
only 24 documented HIVpositive individuals and
6 cases of AIDS in Central Java.2 Fifty-six percent of
the HIV cases were identified among commercial sex
workers (CSWs).4
For many years, the primary mode of transmission
has been heterosexual and, as of 1998, CSWs
accounted for half of the documented HIV cases
in Indonesia.2 Recently there have been changes
in the demographics of those infected. The most
notable shift has been an increase in the percentage
of HIV cases among injection drug users who now
comprise the second largest affected group after
heterosexuals.2
With such an apparently low rate of infection among
high-risk populations, and limited published data
on the subject, researchers have sought to better
understand the extent and nature of the HIV/AIDS
epidemic in Indonesia. Initial research has focused on
highrisk populations of sex workers and their clients
especially in Bali and Jakarta. There have also been a
few studies involving CSWs in Surabaya, but searches
of PubMed and MEDLINE found no published HIV
research conducted in Central Java. Baseline data on
HIV/AIDS in this province is being collected by the
provincial Center for Disease Control, but examination
of the modes of transmission, potential problems in
prevention, and the unique role that Central Java
may play in dissemination of the disease have not
been thoroughly assessed.
157
Social & Behavioral
Syphilis and HIV Prevalence among Commercial
Sex Workers in Central Java, Indonesia:
Risk-Taking Behavior and Attitudes that May
Potentiate a Wider Epidemic
Social & Behavioral
The apparently low prevalence of HIV/AIDS in Central
Java poses a challenge to predicting the most likely
route of its spread through the province and the rest
of Java. We hypothesized that major cities along the
northern highway across Java would be excellent
sentinel sites from which to observe its dissemination
outside of established epicenters.
CSWs and their clients form the largest group
of individuals at high-risk of acquiring and
disseminating HIV and other sexually transmitted
infections (STIs). We conducted a study to determine
the seroprevalence of HIV and syphilis at two brothel
communities situated along the northern Javanese
highway on the outskirts of the Central Java port
city of Tegal. In anticipation of a low HIV prevalence,
we decided to test participants for syphilis in order
to better document not only the extent of HIV and
syphilis infection among CSWs, but also to better
characterize the potential risk for spread of these
diseases. Strong evidence however has shown that
each of the major genital ulcer diseases, syphilis,
genital herpes simplex virus (HSV), and chancroid,
are associated with increased HIV infectiousness
and HIV susceptibility.5 The collected data were
supplemented by a questionnaire and focus groups
in order to better characterize the knowledge, beliefs,
and risk-taking behaviors among CSWs in Central
Java.
Design and measurements
Two hundred CSWs were enrolled using crosssectional methods from the two brothel
communities in the Tegal district of Central Java.
The study was conducted over the course of a
single day in August 2000 and all known CSWs
working at these two sites participated except for
one who was sick.
Native Indonesians, using the Indonesian language
Bahasa Indonesia, conducted all oral and written
communication with participants. The aims of
the study were explained and informed consent
was obtained from every participant before
administering the questionnaire and conducting
the focus groups. A questionnaire was administered
to each participant in order to collect data regarding
sociodemographics and knowledge, beliefs, and
risktaking behaviors. Data was missing in some
questionnaires. Data were analyzed using SPSS/
PC + Version 10.0 (SPSS, Chicago, IL). X 2 Test was
used to find associations between variables and a
p value less than 0.05 was considered significant.6
Survey data were supplemented by conducting
focus groups (n = 520) at both sites.
The project was approved by the Institutional Review
Board at Brown University, the Research Ethics
Committee at Dr. Sardjito General Hospital, Gadjah
Mada University, and the Provincial Ministry of Health
(Departemen Kesehatan), Central Java Province.
Population and ample
The study sample is derived from two communities
of CSWs: Kramat and Tunggal in the Tegal district of
Central Java, Indonesia. HIV status was determined
by two positive enzyme-linked immunosorbent
assay (ELISA) tests (Omega, Stamford, CT, and
Organon, Teknika Corp., Boxtel, The Netherlands)
and confirmed by Western blot test (biuret). Syphilis
status was determined by Venereal Disease Research
Laboratory (VDRL) (Organon/ Shield) testing and
confirmed by TPHA (Organon/Shield) testing. All
participants who tested positive for HIV and/or
syphilis were offered posttest counseling. All who
participants tested syphilis-positive were treated for
free at the expense of the investigators. The study did
not provide funds to give ongoing HIV treatments
and monitoring for individuals found to be infected.
However, follow-up medical care and counseling was
offered for patients who tested positive for HIV.
158
Results
Seroprevalence
One hundred and ninety-nine women and 1 waria
(male-transvestite) (n = 200) CSWs were surveyed.
The mean age was 27.3 years (standard deviation
[SD] 56.08). The prevalence of syphilis and HIV were
7.5% and 0.5%, respectively.
The CSWs in our study were very active sexually and
condom use was low. The mean number of clients
seen per day was 2.27 (SD = 1.36) and 69% reported
having 14 or more partners per week; 29.2% reported
regular use of STI prevention (e.g., condoms, topical
compounds, etc.). When asked specifically about
condom usage, 30.0% said they and their partners
never used condoms during sex, 67.0% reported
occasional use, and 3.0% said they always used
condoms.
representing 0.5% of the CSWs tested. Surveys of
registered sexworkers in Jakarta conducted from
1995 through 1998 found that only 0.1% to 0.2%
tested positive for HIV.7
Focus groups
On the other hand, the prevalence of rate of 7.5% for
syphilis in our study population was slightly higher
than the Provincial Health Service’s data for Central
Java. The Provincial CDC’s blinded sero-survey for the
year 2000 (n = 5710) reported that 5.9% of high-risk
individuals (CSWs) had syphilis (TPHA- and VDRLpositive) while 3.4% were infected with gonorrhea
(smear-culture–positive). Our sample size (n = 200)
was too small to draw conclusions about HIV and
syphilis seroprevalence in Central Java, however,
it is in line with results obtained in government
surveys and other studies. We believe our data is
an accurate representation of the situation in these
two communities of CSWs. While these numbers
suggest a low prevalence of HIV in this high risk
population there may be factors that biased who
enrolled in our study.
In the focus groups, ages ranged from 18–32 years
and participants said they received clients 5 days per
week. The majority of their clients were truck drivers
and sailors and the rest of their clientele consisted
of other travelers passing through the region and a
few locals. Most focus group participants reported
an average of 2 years experience as CSWs and the
majority had previously worked in Jakarta. The
average amount of time they had spent at the study
sites was less than 1 year (range, 1 week to 7 years).
Knowledge of STI signs, symptoms, and prevention
among the CSWs was low. Most had heard of STIs
and AIDs but could not describe common causes
and symptoms. Their primary source for information
was television. Ineffective prevention strategies
such as partner selection (e.g., refusing to have
sex with tattooed clients) and postcoital washing
or douching were common. Participants reported
practicing self-medication to prevent STIs and less
than 10% said they regularly used STI prevention
(e.g., condoms, topical compounds, etc.). Low
frequency of condom use was blamed on problems
of availability and cost.
Social stigma associated with the disease caused
women to fear being tested for HIV and individuals
suspected of being HIV-positive were often forced to
move away because of fears harbored by the rest of
the community.
Discussion
The prevalence of HIV was low in this sample
(0.5%) but 7.5% of the CSWs had a positive test for
syphilis. We documented frequent unprotected
intercourse with highly mobile men from areas of
higher prevalence. Knowledge of the CSWs was low.
This suggests potential for further dissemination
throughout Java.
The size of our sample population (n = 200) and
the number of HIV-positive participants (n = 1)
makes it difficult to draw conclusions about trends
in the prevalence of HIV in this population of CSWs.
Our study only documented one HIV infection
During the economic crisis of 1997, all communities
of CSWs were declared illegal. Since then, prostitution
has slowly increased, both in organized brothels
and on the streets.8 After the economic crisis, local
governments gradually conferred quasi-legitimacy
on a few of the illegal CSW communities. One effect
is that many CSWs move to these “sanctioned”
communities to avoid harassment or arrest. This
serves to concentrate CSWs into large communities
and has enabled the government to more closely
monitor their activities. These unofficially sanctioned
communities are where most of the government
mandated HIV and syphilis testing occurs. CSWs
working there are required to participate in these
annual surveys. At the end of 2000, the provincial
government had record of 39 organized brothels
in Central Java spread throughout the 34 Districts
in Central Java.9 The total number of CSWs in these
centers was approximately 6500.10 It is unknown how
many CSWs operate outside of these communities.
It is likely that there are differences in both in the
prevalence of HIV and syphilis and also in knowledge
of STI signs symptoms and prevention among CSWs
working outside of the brothel communities. Our
study targeted two organized brothel-communities
along the main northern highway on the outskirts
of the city of Tegal, and did not survey CSWs from
unsanctioned communities.
159
Social & Behavioral
Of the CSWs, 23.5% had experienced one or more
symptoms of a STI in the past and 4.5% experienced
STI symptoms within the previous 6 months; 59.1%
reported never having been tested for the HIV virus.
Social & Behavioral
The CSWs who participated in our study focus
groups stated that the vast majority of their clients
were truck drivers passing through the region. Their
second largest client group was sailors using the
ports in Tegal and the rest of their clientele consisted
of other travelers passing through the region and
a few locals. The first two groups are of particular
concern because of the highly mobile nature of
truckers and sailors and the fact that they tend to
have low knowledge of STDs and frequently engage
in risky sexual practices.11,12 One study of truckers,
sailors, and seaport laborers in Jakarta, Surabaya,
and Manado found these groups engaged in high
levels of premarital and extramarital sexual activities
including interactions with CSWs, and condom use
was relatively low even in premarital and extramarital
sexual intercourse.13
The CSWs in our study were very active sexually and
condom use was low. When the issue of low condom
usage was raised in the focus groups the arguments
against condoms were that they are not readily
available near the brothels and when available,
they are too expensive to use. Low condom use
and complaints about availability of condoms has
been found in prior studies in Indonesia.14–18 Better
education and increased access to condoms would
be effective strategies for increasing condom use.
The reports of infrequent STI prophylaxis by CSWs
in our study are concerning. Without prior studies
with which to compare these data we were unable
to tell if the 29.2% who reported regular use of STI
prevention represents either improvement or change
in behavior for CSWs in Central Java. One study in Bali,
comparing AIDS/STD knowledge and behavior found
condom use had increased substantially. However,
despite gains in knowledge related to STDs and HIV,
that study also documented ineffective prevention
strategies and CSW’s perceived susceptibility to STDs
and HIV remained low.19
We found that knowledge of STI signs and symptoms
was limited, as were prevention activities amongst
CSWs in our focus groups. Self-treatment often
meant employment of traditional remedies. Statistics
Indonesia, reported that 27.6% of the general
population use traditional medicine.20 It is unclear
to what extent this number may be extrapolated
directly to medicines for STI prevention but a large
portion of the population relies on this inexpensive
160
form of health care. We did not examine what forms
of prevention were most commonly used by the CSWs
in Tegal. It would be useful for future researchers to
take up this question to determine whether many
CSWs are using ineffective methods of prevention
such as herbal remedies or traditional medicines.
Other ineffective prevention strategies such as
partner selection (e.g., refusing to have sex with
tattooed clients) and postcoital washing or douching
were also reported by focus group participants. This
behavior was due to fears that tattooed individuals
in Indonesia are sterotyped as criminals and the
CSWs feared the possibility of violent behavior by
these clients. Other studies conducted in Indonesia
unfortunately show that client selection practices
and ineffective self-treatment strategies continue to
give these women a false sense of protection from
infection with HIV.19
Some of the focus group participants suggested
that Indonesians’ proclivity toward cleanliness might
be a reason that HIV has not spread more rapidly
throughout the archipelago. A recent study in Bali,
Indonesia, addressed the beliefs that postcoital
washing or douching is an effective means of STI
prevention. It found that 99.1% of the women in
lowpriced brothels used substances such as soap
or toothpaste to clean their vagina at least once
daily and that 69.3% of them cleaned this way after
each sexual partner.21 The women who cleaned in
this manner after each intercourse had a higher
prevalence of genital infections but lower levels of
reported genital symptoms. They also had fewer
genital symptoms than women not cleaning their
vagina after sex, but the practice had no effect on
the prevalence of STDs among the groups.21 This
belief that washing ones’ genitalia after sex will
prevent HIV and STIs may be prevalent throughout
Indonesian society. More studies are necessary to
further characterize the perceptions and effects of
vaginal cleansing practices on the prevalence of STIs
and HIV in Indonesia and to assess the frequency of
such ineffective prevention practices.
Although 40.9% of those surveyed reported that they
had been tested for HIV in the past, only a handful
knew the results of the test. There are not enough
people trained to provide pre-test and post-test
counseling and so many of the CSWs may not fully
comprehend that blood is being drawn to test for
Most of the women said they were afraid to find out
about their HIV status because of the extreme social
stigmas associated with the disease. Women in the
focus groups related how individuals suspected of
being HIV-positive are often forced out of communities
because of fears harbored by the rest of the community.
They are afraid the government might shut down
their community or that clients will become fearful
of contact with any of the CSWs there. The women
we spoke with said that most of them would leave a
brothel-community if they tested positive for HIV. They
would rather flee than face the possible social isolation
and persecution that might come should others
learn of their HIV-positive status. Given the current
misconceptions and attitudes toward HIV and AIDS in
Indonesia, mandatory testing puts participating CSWs
at risk for persecution and social isolation if others
suspect that they are HIV-positive.
Some observers have suggested that there may be
variations in sexual practices that make Indonesian
CSWs less likely to acquire HIV. Studies have
documented lower numbers of customers per sex
worker in Indonesia than neighboring countries with
much higher rates of infection. However, the STD
prevalence rates among high-risk groups suggests
that significant levels of exposure do occur and most
observers agree that the number of documented HIV
and AIDS cases is far lower than the actual numbers
infected.
Although HIV prevalence in Central Java may suggest
a pre-epidemic state, we found that insufficient
knowledge about HIV and STDs among CSWs and
limited self-protective behaviors pose barriers
to effective prevention efforts, suggesting great
potential for wider dissemination.
References
1.
Epidemiological Fact Sheet on HIV/AIDS and Sexually
Transmitted Infections; Indonesia, 2002 Update: UNAIDS/
WHO; 2002.
2.
In: Ministry of Health, Republic of Indonesia; 2002.
3.
Population Census 2000, Preliminary Results: Official Statistics
News; 2000.
4.
Monthly Feedback HIV and AIDS Cases [unpublished report]:
Directorate General of the Center for Disease Control and
Indonesia Ministry of Health; 2000 December, 2000.
5.
Fleming DT, Wasserheit JN. From epidemiological synergy to
public health policy and practice: the contribution of other
sexually transmitted diseases to sexual transmission of HIV
infection. Sex Transm Infect 1999;75:3–17.
6.
Pedhazur EJ, Schmelkin LP. Measurement, Design, and
Analysis: An integrated Approach. Hillsdale, NJ: Lawrence
Erlbaum Associates, 1991. 7. Epidemiological Fact Sheet on
HIV/AIDS and Sexually Transmitted Infections; Indonesia, 2000
Update (revised): UNAIDS/WHO; 2000.
8.
Abednego H. Current Situation and Trend of HIV/ AIDS
epidemic in Indonesia. In: International Conference on AIDS,
1998. NIH/NLM AIDSLINE; 1998.
9.
Report on Surveillance of Syphilis and HIV for the year 1999–
2000 [unpublished report]: Central Java Ministry of Health;
2000.
10. Annual Regional Report [unpublished report]: Ministry of
Health, Central Java Province; 2000.
11. Dayton JM, Merson MH. Global dimensions of the AIDS
epidemic: Implications for prevention and care. Infect Dis Clin
North Am 2000;14:791–808.
12. AIDS Epidemic Update: December 2000: UNAIDS/ WHO; 2000.
13. Utomo B. Baseline STD/HIV Risk Behavior Surveillance Survey
1996. Results from the cities of North Jakarta, Surabaya, and
Manado: Center of Health Research, University of Indonesia,
1998.
14. Lubis I, Master J, Munif A, et al. Second report of AIDS related
attitudes and sexual practices of the Jakarta Waria (male
transvestites) in 1995. Southeast Asian J Trop Med Public
Health 1997;28:525–529.
15. Joesoef MR, Linnan M, Barakbah Y, Idajadi A, Kambodji A,
Schulz K. Patterns of sexually transmitted diseases in female
sex workers in Surabaya, Indonesia. Int J STD AIDS 1997;8:576–
580.
16. Joesoef MR, Kio D, Linnan M, Kamboji A, Barakbah Y, Idajadi
A. Determinants of condom use in female sex workers in
Surabaya, Indonesia. Int J STD AIDS 2000;11:262–265.
17. Ford K, Wirawan DN, Fajans P. AIDS knowledge, risk behaviors,
and condom use among four groups of female sex workers in
Bali, Indonesia. J Acquir Immune Defic Syndr Hum Retrovirol
1995;10:569–576.
18. Fajans P, Wirawan DN, Ford K. STD knowledge and behaviours
among clients of female sex workers in Bali, Indonesia. AIDS
Care 1994;6:459–475. 19. Ford K, Wirawan DN, Reed BD,
Muliawan P, Sutarga M. AIDS and STD knowledge, condom
use and HIV/STD infection among female sex workers in Bali,
Indonesia. AIDS Care 2000;12:523–534. 20. Social Welfare
Statistics: Selected Tables. In: Statistics Indonesia (Badan Pusat
Statistik); 2002.
21. Reed BD, Ford K, Wirawan DN. The Bali STD/AIDS study:
Association between vaginal hygiene practices and STDs
among sex workers. Sex Transm Infect 2001;77:46–52.
161
Social & Behavioral
HIV as well as STIs. Some of the women may receive
proper counseling and others may not. Most likely
it is a combination of these three reasons that best
explains who so many women report never having
been tested. The aforementioned issue of incomplete
pre-test and post-test counseling surfaced during
the course of our research study. While we were able
to provide pretest counseling for the participants,
the dearth of trained counselors forced us to target
our posttest counseling to the 30 CSWs who were
VDRL and/or HIV-positive. This shortage of well
trained counselors is an obstacle to informing survey
participants of their post-test HIV status.
Social & Behavioral
Voluntary HIV Testing, Disclosure,
and Stigma among Injection Drug Users
in Bali, Indonesia
Kathleen Ford1
Gusti Made Sumantera2
Anak Agung Sagung Sawitri2
Mandy Stahre1
1
2
AIDS Educ Prev. 2004 Dec; 16(6): 487–498
163
Abstract
Recently, large increases have been noted in injection drug use and HIV prevalence . in Indonesia. Because voluntary HIV counseling and testing
can play an important role in HIV prevention, it is important to understand factors related to its use. The objective of this study was to identify
factors related to the use of voluntary HIV testing among drug users. In–depth interviews were conducted with a sample of 40 drug users in the
Denpasar area of Bali, Indonesia. Drug usersmay be interested in testing if they have enough information about AIDS to know that they are at
risk and that they need this information to protect themselves and others from infection. Barriers toward testing included the fear of a positive
result, fear of reactions from family and community members and stigmatization.
Other obstacles include a feeling of hopelessness, problems with testing, unavailability and side effects ofAIDS drugs and other factors. Many
persons would not disclose their status to community members and sexual partners. Therewere serious concerns about others being ashamed of
them and the impact of HIV on relationships with spouses and sexual partners and on employment.
The experience of Indonesia, the world’s fourth most
populous country, shows how quickly an epidemic
can emerge (UNAIDS, 2002). After more than a decade
of negligible HIV prevalence rates, the country is
now seeing infection rates increase rapidly among
injecton drug users (IDUs) and sex workers, in some
places along with an exponential rise in infection
among blood donors (an indication of HIV spread
in the population at large) (Wirawan, 2002). In 1987
the first AIDS case was found and seroprevalence
remained low until 1999. In 2000 the number of AIDS
cases tripled and this trend has continued (Ministry
of Health, 2001). Recent studies of drug using
communities have found seroprevalence rates of 40%
to 53%, and those of sex workers are also increasing
(6–26%) (Wirawan, 2002). The situation in Indonesia
under lines the fact that where risky behavior exists,
the epidemic may spread, even if it takes some years
for the spread to become apparent (UNAIDS, 2002).
Drug Use in Indonesia
Within the past 3 years, there has been a massive
increase in injecting drug use in Indonesia, with
at least 300,000 IDUs now estimated among its
population of over 200 million. Heroin is the drug
most often reported to be used by IDUs. The most
common method of using the drug is injection,
although “chasing the dragon” (a method of inhaling
the drug while burning it underneath tin foil) has
also been reported. At the same time, although the
HIV infection rate in Indonesia is lower than in many
countries, the majority of the recently reported
cases have been among IDUs. Indeed, almost 90% of
new cases of HIV/AIDS reported in 2000/2001 were
among IDUs. Furthermore, in Bali and Java, rates of
HIV infection among in–treatment drug users range
from 10% to 50% (Wirawan, 2002). Although drug use
is increasing in Indonesia, it is still heavily stigmatized
among the general population.
A study was conducted inDenpasar, Bali, in 1998
among groups of drug users in the city of Denpasar
and in the nearby tourist resort ofKuta (Setiawan et al.,
1998). Most of the drug users in this study were male
(88%), aged 20–29, with some high school education.
About half were originally from Bali and the other half
had moved from other Indonesian islands.About half
of the respondents reported that they had been in
jail. Themost common first drugs used weremarijuana
(38%), barbiturates (35%), and heroin (15%). Almost all
reported heroin to be the main drug that they currently
use. About 85% reported injecting the heroin and 15%
reported “chasing the dragon.”
Barriers Toward and Motivators For
HIV Testing
There may be many obstacles blocking the use of
HIV testing among drug users. Quantitative studies
of drug users in the U.S. have identified a number of
factors related to seeking testing. Variables related to
health and illness as well as high–risk behaviors were
most strongly associated with HIV testing (Davis,
165
Social & Behavioral
Voluntary HIV Testing, Disclosure,
and Stigma among Injection Drug Users
in Bali, Indonesia
Social & Behavioral
Deren, Beardsley, Wenston,&Tivtu, 1997). Other
factors included perceived and actual risk of HIV
infection (McCusker et al., 1994), previous negative
test results, longer stay in drug treatment, and
AIDS education programs (McCusker et al., 1997).
A meta-analysis of 198 studies identified personal
risk, counselor characteristics, confidentiality, and
access to treatment to be important factors (Irwin,
1993). Sexual risk behaviors and injection drug use
were strong predictors of testing in another study
(Solomon, Moore, Astemborski, & Vlahovl, 1996).
In a study of 66 drug users in the San Francisco Bay
area, multiple factors were found to be associated
with the use of testing (Downing et al., 2001). Personal
factors associated with obtaining HIV testing included
self perceived risk of HIV infection. This perceived risk
included not only the individual’s risk behaviors but
also an assessment of the environment. Protecting
family members and the encouragement of peers
were also important. Deterring factors included
fear of receiving a positive result, lack of perceived
risk, the stigma of HIV infection, and a partner
with a negative result. Structural factors that were
important in testing included the quality of the staff,
incentives, convenience, links with other services,
and site atmosphere.
Some gender differences in use of HIV testing have
also been identified. Pregnancy may be an important
motivating factor for women to seek HIV testing
(Downing et al., 2001). In a study of gender differences
in psychosocial and behavioral predictors of HIV
testing, Stein and Nyamathi (2000) found that social
support was more important for women than for
men and that men were more likely to underestimate
heir risk for HIV infection.
Stigma and discrimination may also prevent
persons from being tested (Maman, Mbwambo,
Hogan, Kilonzo, 2001; Spielberg, Kurth, Gorbach, &
Goldbaum, 2001). Stigma and discrimination not
only prevents persons from being tested but may
also prevent individuals from obtaining treatment
for AIDS. Stigma has been defined as an attribute
“that is deeply discrediting” to a person in a social
group (Goffman, 1963). Herek (1999) defined two
types of stigma associated with AIDS; instrumental
and symbolic. Instrumental stigma is linked to the
real or imagined fear of getting the disease. Symbolic
stigmais associated with activities such as promiscuity
and illicit drug use that bear a large measure of
social disapproval. As Parker and Aggleton (2002)
have noted, there is a synergy between preexisting
sources of stigma toward groups such as drug users
that is linked to HIV and AIDS that limits our ability to
develop effective responses to it.
In a study of voluntary counseling and testing in
Tanzania, Kenya, and Trinidad, the investigators
found that people perceived many benefits to
HIV testing (Grinsted, Gregorich, Choi,& Coates,
2001; Sangiwa et al., 1998). Many people wanted
to be tested and those who did were more likely to
reduce unprotected intercourse. Negative effects of
testing did occur, including physical assault (1.2%),
TABLE 1. Demographic and Drug–Using Characteristics of Sample
Variables
Age groups
< 25
25–29
30+
Martial Status
Married
Divorced/separated
Not married
Gender
Male
Female
Length of stay in Bali
Since birth
1 month – < 6 months
6 months – < 1 yr
More than 1 year
166
Frequency
Percentage of total population
17
13
10
42.5
32.5
25
7
3
30
17.5
7.5
75
35
5
87.5
12.5
14
6
1
19
35
15
2.5
47.5
abandonment (1.2%), and being forced to leave
home (0.8%), although these were relatively rare
in the study. The majority of both HIV-positive and
HIV-negative women disclosed their results to their
partners.
Objectives
Although numerous studies on HIV testing and drug
users have been conducted in the U.S., few studies
have been conducted in Asia, and to our knowledge
there are no published studies from Indonesia.
Given the escalation of the epidemic in this country,
an understanding of the factors that influence
testing among drug users is essential for the further
development of HIV-testing services in this area.
The objective of this study was to identify factors
related to the use of voluntary HIV testing among
drug users. A conceptual framework for the study
23
10
7
57.5
25
17.5
6
5
21
8
15
12.5
52.5
20
was drawn from the health belief model (HBM). This
model posits that individual’s actions are based on
beliefs (Rosenstock, Strecher,&Becker, 1994). This
model identifies key elements of decision making
such as the person’s perception of susceptibility,
perceived severity of the illness, and the perceived
benefits and barriers to prevention.
Methods
The main methodology used to identify factors
related to HIV testing was in–depth interviews.
Forty drug users were interviewed face–to–face by
two interviewers. Both interviewers had previous
experience with qualitative data collection in Bali. The
interviewers were native speakers who conducted
the interviews in Bahasa Indonesia. Both interviewers
used the same interview guides and procedures
during data collection. Fieldwork was conducted
from April through September 2002.
TABLE 2. Sexual and Drug Use Behaviors of Respondents
Drug use status
Active user
Former user
Most common drugs ever used
Heroin
Marijuana/hashish
Shabu–shabu/methamphetamine
Nitrazapan/Koblo/Nipan
Cocaine
Ecstasy
HIV–testing status
Ever tested
Never tested
HIV status of tested persons
Positive
Negative
At least one sex partner in last year
Mean sex partners in last year (Range)
Paid partner in last year
Respondent paid
Respondent was paid
N
%
20
20
50
50
40
36
31
24
15
12
100
90
77.5
60
37.5
30
19
21
47.5
52.5
9
10
35
4.3 (1–30)
10
8
2
47.4
52.6
87.0
29.0
23.0
6.0
167
Social & Behavioral
Religion
Muslim
Christian
Hindu
Education level
Elementary
Junior high school
Senior high school
University
Social & Behavioral
Sexual orientation of partners
Heterosexual
Bisexual
Homosexual
Ever used a condom
Total N
The drug users were recruited through the counselors
and outreach workers through three community
agencies that provide services to drug users.
Fieldworkers from these organizations spoke to drug
users about the study and invited them to participate.
Both current and former drug users were included in
the study. All of the drug users had injected heroin.
Both groups were included because the majority of
users who have been tested have not been current
users. Participants in these interviews were offered
refreshments including cold drinks and food and
free HIV testing at the Kerti Praja Clinic. The study
was approved by the institutional review boards
of the Kerti Praja Foundation and the University of
Michigan.
34
1
0
34
40
97.0
3.0
0.0
85.0
100
Development of the questionnaire was guided by
the constructs of the HBM. Drawing on the main
constructs of the HBM, a number of open and
close ended questions were included to identify
factors associated with testing including perceived
susceptibility toward AIDS, knowledge of AIDS,
and the benefits and barriers toward HIV testing.
Due to its importance in the literature, a few close
ended questions on stigma and disclosure were
also included. Finally, the questionnaire included a
number of close ended questions on demographics
including age and migration history, drug use history,
sexual history, and AIDS and STD knowledge. These
questions were included to provide a description of
the study population.
TABLE 3. Benefits of HIV Testing: Responses to the Question
“Why Do Drug Users in Bali Look for HIV Testing?”
Response
Want to protect
Their own health
Others from infection
Self from infection
Awareness of possible infection
Want to know status
Ready to receive result
Think they may be positive
Showed symptoms of AIDS
Need to know for future plans including marriage and school
Participate in risky behavior (in general)
Sex with CSW or without condoms
Share needles
AIDS information
Taught information about AIDS
Think AIDS can be spread by injecting drugs
Influence of others
A friend asked them to get tested
To consult with doctors if HIV–positive
Required by drug rehab center
Don’t know
Other reasons
Number of respondents
Note. CSW = commercial sex worker.
168
All (%)
Current
Users
Former
Users HIV–Positive
32.5
35
22.5
15
20
30
50
50
15
66.7
44.4
11.1
65
5
7.5
5
12.5
22.5
10
27.5
80
10
0
0
10
25
20
45
50
0
15
10
15
20
0
10
44.4
0
11.1
11.1
22.2
44.4
11.1
11.1
17.5
5
5
0
30
10
44.4
22.2
5
2.5
5
7.5
7.5
40
10
5
5
10
5
20
0
0
5
5
10
20
0
0
0
0
22.2
9
either born in Bali (35%) or had been there more
than 1 year (47.5%). The majority of users were of the
Muslim religion (57%), followed by Christians (25%)
and Hindus (17%). More than70%had at least some
high school and20%had been to the university.
Results
Half of the sample were former drug users and half
were active users (Table 2). The most common
drugs used (reported by more than 30% of users)
were heroin (100%), marijuana or hashish (90%),
methamphetamine (shabu–shabu) (77%), nitrazepam
(60%), cocaine (37%), and ecstasy (30%). Use of
sedatives such as valium and lexothane was also
reported along with other drugs such as rohypnol.
Demographics, Drug Use, and Sexual Behavior
Table 1 shows the demographic characteristics of the
study sample. The study sample is mainly a young
population with 42.5% under age 25, 32.5% aged 25–
29, and 10% aged 30 or older. Most were not married
(75%); others were married (17.5%) or divorced or
separated (7.5%). The majority of respondents were
TABLE 4. Barriers Toward HIV Testing: Responses to the Question
“Why Do Drug Users in Bali Avoid HIV Testing?”
Response
Fear of
Positive result
Death from AIDS
Reaction from friends if positive
Family reaction if positive
Community reaction
Stigmatization
Feel ashamed about drug use
Will not reply to questions from others about status
No cure for AIDS
Can do nothing if positive
Too busy getting drugs
Concern about confidentiality
Lack of Understanding About
HIV test
How AIDS is transmitted through drug use
Risk for others
Where to go for testing
Cost of testing
Problems with testing
Long wait for result
Don’t have anyone to go with for support
Hospital procedures are complicated
Don’t like blood drawn
AIDS Drugs
Are unavailable
Are expensive
Have side effects
Other Problems with Testing
Don’t believe test results
Don’t want to be in an experiment
Don’t want to use money for testing
Doctors will not help if positive
Don’t want to think about testing
Believe they are positive so don’t need to test
Number of respondents
All
Current
Users
Former
Users
HIV–Positive
55
37.5
10
7.5
10
40
10
2.5
17.5
25
25
15
55
30
15
0.0
0.0
30
15
5
25
10
30
25
55
45
5
15
20
50
5
0.0
10
40
20
5
55.6
44.4
0
22.2
44.4
22.2
11.1
0
11.1
55
33.3
11.1
20
15
5
7.5
20
20
5
5
15
20
20
25
5
0.0
20
22.2
44.4
0
0
22.2
2.5
2.5
2.5
2.5
0.0
5
5
5
5
0.0
0.0
0.0
0
0
0
0
2.5
5
2.5
5
0.0
0.0
0.0
10
5
0
11.1
11.1
2.5
2.5
7.5
2.5
5
5
40
5
5
15
5
5
0.0
20
0.0
0.0
0.0
0.0
5
10
20
11.1
11.1
0
0
0
11.1
9
169
Social & Behavioral
Responses to open ended questions were reviewed in
Bali by two native Indonesian speakers for common
themes. Common themes were then coded into
response categories. Each respondent was included
in as many response categories as they reported.
Social & Behavioral
TABLE 5. If Medication to Treat AIDS Were Available, Would Drug Users be Interested in Testing?
Response
Acceptance
Medication would outweigh resistance to testing
Conditional Acceptance
Only if the medication can cure AIDS
If the disease can be managed with medication
Media reports no cure so medication is not possible
Medication must be cheap or free
May have only a small effect on testing, barriers
hard to overcome
Only if community is prepared to accept HIV–positive
IDU
Would need more info on medication
Medication must have small side effects
Drug Use Status
Active users are more concerned with drugs
than their HIV status
May be more important for ex–users
Total
Percent
Current
Users
Former
Users
HIV–Positive
40
30
50
55.6
15
7.5
2.5
17.5
30
10
5
15
0
5
0
20
0
0
11.1
33.3
22.5
20
25
11.1
5
2.5
2.5
5
5
5
5
0
0
0
0
0
10
2.5
40.0
5
0
20.0
15
5
20.0
11.1
0
9.0
Note. IDU = injection drug user.
Almost half of the sample had been tested for HIV
(47%) and 47% of those persons were HIV-positive.
themselves from infection (22%), and to protect
others from infection (35%).
Most of the respondents (85%) reported at least
one sexual partner in the last ,year. The average
number of partners was 4.3 (range = 1–30). Ten of the
respondents reported paid sex. Eighty percent of the
drug users reported paying for sex rather than being
paid (20%). Most partnerships were heterosexual,
with only one respondent reporting partners of both
genders.
Awareness of risky behavior was also given as a
reason for interest in testing (23%). Other risky
behaviors mentioned were sex with sex workers
and sex without using condoms (10%) and sharing
needles (27%). Education about AIDS was reported as
a motivator for HIV testing. The respondents reported
that as drug users receive more information about
AIDS (17%) and are aware that AIDS can be spread by
injecting drugs (5%) they may be more interested in
testing. They also noted that HIV testing is important
to plan for marriage and education (12%).
Benefits Of HIV Testing
The respondents were asked about the benefits of
testing for drug users and their coded responses
are shown in Table 3. The most often mentioned
response was that they wanted to know their status
(65%). The next most common responses related to
the protection of their own health (33%), to protect
The main reasons that drug users would want to
be tested for HIV that were reported by current and
former drug users were similar. Knowing one’s status
and protecting one’s health and the health of others
TABLE 6. Persons to Whom the Respondents Would Disclose Their HIV Status or Who Would Feel
Ashamed of the Respondent
Your spouse
Your sexual partners
Your children
Your brothers
170
All
77.8
62.5
12.5
51.5
Would Disclose To
Current
Former
Users
Users
83.3
66.7
50.0
75.0
25.0
0.0
43.8
58.8
HIV–
Positive
66.7
71.4
0.0
44.4
Would be Ashamed Of
Current
Former
All
Users
Users
77.8
66.7
100.0
50.0
75.0
25.0
75.0
75.0
75.0
51.5
68.8
35.3
HIV–
Positive
66.7
0.0
33.3
11.1
51.5
55.0
52.5
40.0
0.0
40.0
5.0
92.5
57.9
52.5
40
35.5
45.0
30.0
11.1
0.0
50.0
5.0
90.0
0.0
55.0
20
68.8
65.0
75.0
63.6
0.0
30.0
5.0
95.0
78.6
50.0
20
75.0
77.8
88.9
80.0
0.0
11.1
0.0
88.9
83.3
55.6
9
51.5
55.0
45.0
45.0
57.5
40.0
55.0
5.0
10.5
45.0
40
58.8
70.0
70.0
66.7
60.0
50.0
65.0
5.0
20.0
45.0
20
43.8
40.0
20.0
27.3
55.0
30.0
45.0
5.0
7.1
45.0
20
12.5
22.2
0.0
20.0
44.4
44.4
55.6
0.0
0.0
44.4
9
Note. IDU = injection drug user.
were the most important. Responses were also similar
for HIV-positive respondents.
Barriers Toward HIV Testing
Table 4 shows the responses to the question “Why do
drug users avoid HIV testing?” The most important
reasons given for avoiding testing were fear of a positive
result (55%) and fear of death from AIDS (37%).
Stigmatization of HIV-positive persons was also
a reported concern about HIV testing. Many
respondents (40%) were concerned about
stigmatization in general (40%), whereas others
mentioned the reaction of friends (10%), family (7%)
and the community (10%).
The respondents also reported that the lack of a cure
or effective treatment for AIDS was a barrier to HIV
testing. Some (17%) mentioned that there was not
a cure for AIDS and 25% responded that nothing
can be done if someone has AIDS. Active drug users
may also be too concerned about obtaining drugs to
consider testing (25%).
Lack of information about AIDS and HIV testing
may also be reducing the demand for HIV testing.
Respondents reported that there was a lack of
understanding about the HIV test (20%), how AIDS
is transmitted through drug use (15%), the risk to
others (5%), where to go for testing (7%), and the
cost of testing (20%).
Several respondents reported problems with the
testing process. These included a long wait for the
result (2.5%), no one to go with for support (2.5%),
complicated hospital procedures (2.5%), or a dislike
of having their blood drawn (2.5%). Concerns about
confidentiality may also be an issue (15%).
Other respondents thought that drug users would
avoid testing because of negative information
that they had received about AIDS drugs. These
comments were that AIDS drugs were unavailable
(2.5%), expensive (5.0%), or have side effects
(2.5%).
Finally, drug users had a number of additional
negative comments about testing including they
don’t believe test results (2.5%), they don’t want
to be in an experiment (2.5%), they don’t want to
use money for testing (7.5%), doctors won’t help
if positive (2.5%), they don’t want to think about
TABLE 7. If You Tested Positive for HIV, How Likely Is It That The Following Would Happen?
Result
Negative Effects
Breakup of marriage
Physical abuse by spouse/sexual partner
Breakup of sexual relationships
Neglected by family
Disowned by family
Discrimination by employers
Estrangement by other drug users
All
Former
Users
Current
Users
HIV–Positive
66.7
25.7
86.1
35
32.5
66.7
82.5
66.7
31.6
78.9
30
30
100
90
66.7
18.8
94.1
40
35
56.3
75
66.7
28.6
87.5
44.4
44.4
33.3
66.7
171
Social & Behavioral
Your sisters
Your other relatives
Your friends
Your landlord
Your neighbors
Your religious leader
Your community leader
Your physician
Your employer
Other drug users
N
Social & Behavioral
Positive Effects
Increased emotional support from employers
Increased emotional support from peers
Strengthening of relationship with spouse/sexual partner
Increased emotional support from family/relatives
Increased emotional support from health professionals
N
testing (5%), or they believe they are positive so
they don’t need to test (5%).
Most results were similar for former and current drug
users and HIV-positive persons.
Availability Of Medication
Respondents were asked if the availability of
medication would make drug users more interested
in testing (Table 5). Many respondents thought
that medication use would outweigh resistance to
testing (40%). This was mentioned most often by
former drug users (50%) and HIV-positive persons
(56%). In contrast, other respondents thought that
this would be conditioned upon whether the disease
can be cured (15%) or managed (7.5%). More correct
information from the media may be necessary (2.5%).
The medication must also be cheap or free (17%) and
have few side effects (2.5%). Also, the community
must be ready to accept HIV-positive drug users (5%).
Anumber of others thought that the availability of
medication would only have a small effect (22%).
Drug use status may also influence the effect of the
availability of medication on testing. It may be more
important for ex–users (2.5%) than for current users
(10%).
Consequences Of Testing: Stigmatization
The drug users who participated in the study were
asked in two closed ended questions who they would
disclose their status to and who would be ashamed
of them (Table 6). Nearly all persons would disclose to
their physician (92%) and most to their spouse (78%).
More than half would disclose to their sexual partners
(62%) and their employers (58%); relatives (52%),
including brothers (51%) and sisters (51%); friends
(52%); and other drug users (52%). Further down the
list were landlords (40%) and religious leaders (40%).
Few would tell their children (12%) and community
leaders (5%). None of the respondents would tell
their neighbors.
172
90.5
85
60
92.5
97.5
40
80
85
42.1
95
100
20
93.8
85
81.3
90
95
20
100
66.7
100
100
100
9
In general, HIV-positive persons reported that they
would disclose to physicians, family members,
spouses, friends, and sexual partners. However, they
also reported that they would not tell their children,
their neighbors, or their community leaders.
Apart from physicians and employers, the
respondents reported that at least40% of other
persons would be ashamed of them. The drug
users’ spouse (78%) and children (75%) would be
most likely to disapprove. HIV-positive persons
reported that their spouse would be most likely
to be ashamed of them (67%), followed by their
community leaders (56%), their neighbors (44%),
and their religious leaders (44%).
Consequences Of A Positive Test
In a close–ended question, respondents were
asked what would happen if they received a
positive test (Table 7). Likely negative effects
included the breakup of sexual relationships
(86%), estrangement by other drug users (82%),
breakup of marriage (67%), and discrimination by
employers (67%). A smaller proportion predicted
being neglected (35%) or disowned (32%) by
their family or physical abuse (26%) by a spouse
or sexual partner.
Most also thought that they would receive positive
support from a number of sources. Increased emotional
support was expected from health professionals
(97%), family/relatives (92%), employers (90%), and
peers (85%). Many also predicted a strengthening
of their relationship with a spouse or partner (60%).
HIV-positive persons reported increased emotional
support from health professional (100%), employers
(100%), family/relatives (100%), and peers (67%). They
also reported a strengthening of the relationship with
a spouse/sexual partner (100%). Negative effects
were the breakup of sexual relationships (87%),
marriages (67%), and estrangement from other drug
users (67%).
A number of obstacles toward testing were also
identified including the fear of a positive result, fear of
reactions from family and community members and
other problems with stigmatization. Other obstacles
include a feeling of hopelessness, because there is no
cure for the disease.
Additional issues included a lack of information
about AIDS, problems with testing, lack of availability
and side effects of AIDS drugs, and other factors.
Opinions were divided among users as to whether
the availability of drugs would increase the use of
testing. Active drug users may be too concerned with
obtaining drugs to consider these options.
Many persons would not disclose their status to
community members and sexual partners. There
were serious concerns about others being ashamed
of them and the impact of HIV on relationships with
spouses and sexual partners. Discrimination by
employers was also a concern. On the positive side,
respondents expected increased emotional support
from employers, peers, and families.
Some factors related to HIV testing were similar to
those obtained in other studies. These included
perceived susceptibility to HIV, knowledge of risk
behaviors, fear of a positive result, and concerns about
confidentiality. The limited availability of information
from the media may also be a factor. The need for
a better understanding of how HIV is transmitted
and the options for treatment may be greater in
this population due to the more limited services for
drug users. Lack of certainly regarding the efficacy
and availability of antiretroviral medications is a very
serious concern in this area. Information is scarce
among drug users and current availability is very
limited. Efforts are being made by nongovernmental
organizations, international groups, and government
groups in Indonesia to improve this situation.
Programs in this area could help to promote HIV
testing by increasing access to accurate information
about AIDS in the drug-using population. Although
outreach to users already exists, more information
needs to be made available to users. This might be
done by increasing outreach to these people, through
media and through workplace, clinic, and community
interventions. The availability of medication,
combined with efforts to spread correct information,
may also assist in increasing HIV testing.
Programs to increase the acceptance of HIV-positive
persons in the community are also needed. As Parker
and Aggleton (2002) have indicated, increasing
the acceptance of HIV-positive drug users in the
community is a difficult process that may need to
include structural changes in the legal system as well
as community mobilization.
In summary, there are a number of obstacles in the
way of increasing HIV testing in Indonesia. Both
individual and community-based interventions may
be needed to accelerate the use of HIV testing.
References
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Gender differences and other factors associated with HIV
testing in a national sample of HIV drug users. AIDS Education
and Prevention, 9(4): 342–358.
Downing, M., Knight, K., Reiss, T.H., Vernon, K., Mulia, N., Ferreboeuf,
M., et al. (2001). Drug users talk about HIV testing: motivating
and deterring factors. AIDS Care, 13(5), 561–577.
Goffman, E. (1963). Stigma: Notes on the management of spoiled
identity. Englewood Cliffs, NJ: Prentice-Hall.
Grinstead, O.A., Gregorich, S.E., Choi, K.H., & Coates, T. (2001).
Positive and negative life events after counseling and testing:
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Herek, G.M. (1999).AIDS and stigma. InAIDS and stigma in the
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Irwin, K. (1993, December). The acceptability of voluntary HIV
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Maman, S., Mbwambo, J., Hogan, N.M., & Kilonzo, G.P. (2001).
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McCusker, J., Bigelow, C., Zapka, J.G., Zorn, M., Stoddard, A.M., &
Lewis, B.F. (1994). HIV–1 antibody testing among drug users
participating in AIDS education. Patient Education and
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173
Social & Behavioral
Summary And Discussion
This study has confirmed that a number of constructs
relevant to the HBM were associated with HIV testing.
AIDS knowledge and perceived susceptibility to the
disease were identified in the interviews. In addition,
a number of benefits and barriers toward HIV testing
were described by the drug users. Drug users may be
interested in testing if they have enough information
about AIDS to know that they are at risk and that they
need this information to protect themselves and
others from infection.
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Ministry of Health. (2001). Statistical cases of HIV/AIDS in Indonesia.
Directorate General CDC and EH, Ministry of Health, Republic
of Indonesia. Update. Retrieved from http://www1.rad.net.id/
aids/data.htm.
Spielberg, F., Kurth, A., Gorbach, P.M., & Goldbaum, G. (2001).
Moving from apprehension to action: HIV counseling and
testing Preferences in three at–risk populations. AIDS
Education and Prevention, 13(6), 524–540.
Parker, R., & Aggleton, P. (2002). HIV and AIDS–related discrimination:
a conceptual framework and implications for action. Rio de
Janero, Brazil: ABIA. Rosenstock, I.M., Strecher, V., & Becker,
M.H. (1994). The Health Belief Model and HIV risk behavior
change. In R.J. DiClemente & J.L. Peterson (Eds.), Preventing
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Stein, J.A. & Nyamathi, A. (2000). Gender differences in behavioral
and psychosocial predictors of HIV texting and return for test
results in a high risk population. AIDS Care, 12(3), 343–356.
Sangiwa, G., Balmer, D., Furlonge, C., Grinstead, O., Ky–Inga, M.,
Coates, T., et al. (1998, July). Voluntary HIV counseling and
testing (VCT) reduces risk behavior in developing countries:
Results from the Voluntary Counseling and Testing Study.
Paper presented at the 12th World AIDS Conference, Geneva,
Switzerland.
Setiawan,M. et al. (1998). A study of the drug using community
in the Denpasar area. Unpublished manuscript. Solomon,
L.,Moore, J., Astemborski, J.,&Vlahov, D. (1996).HIV testing
behaviors in a population of inner city women at high risk
of HIV infection. Journal of Acquired Immune Deficiency
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UNAIDS (2002). Report on the global HIV/AIDS epidemic. Geneva,
Switzerland: Author.
Wirawan, D.N. (2002, September). The HIV/AIDS epidemic in
Indonesia. Paper presented at the TREAT ASIA Conference,
Bangkok, Thailand.
Hepa Susami1,2
Samsuridjal Djauzi2
Cut Antara Keumala2
1
Master Student in Universiteit Maastricht, The Netherlands.
2
Special Working Group on AIDS FKUI/RSCM (Pokdisus AIDS FKUI/RSCM)
Jakarta, Indonesia.
HIV Matters. 2009 Jun;4(1):7-10
Published by Australian Society on HIV Medicine (ASHM)
175
Social & Behavioral
Factors Influencing Pregnancy Decision-Making of
HIV Positive Women in Jakarta, Indonesia
Introduction
Over the past 20 years, the HIV epidemic in Indonesia
has changed drastically. The first HIV case in Indonesia
was diagnosed in 1986 in Bali. Since then, cases
have escalated significantly. The current estimated
number of people living with HIV in Indonesia is
270,000 (UNAIDS 2008), and 986 new cases of HIV
were diagnosed in 2007 alone (AIDS-INA 2008).
According to the monthly report of the Ministry of
Health (AIDS-INA, 2008), almost half (39%) of the new
HIV cases found in Indonesia were among women. It
is unlikely that the infection rates of HIV in women
will decline anytime soon.
The ability to choose when and whether to have
children is considered a basic human right. While
these reproductive rights are widely accepted, issues
surrounding sexual activity and childbearing among
HIV-positive women raise a number of complex issues
(Myer, Morroni, & Cooper, 2006; Ngwena & Cook, 2008).
As women, they have the desire to have children of
their own (Cooper et al., 2007; Craft, Delaney, Bautista,
& Serovich, 2007; Kirshenbaum et al., 2004; Kline,
Strickler, & Kempf, 1995; Paiva et al., 2007; Richter,
Sowell, & Pluto, 2002; Siegel & Schrimshaw, 2001;
Wesley et al., 2000). The fact of their HIV-positive status
does not prominently influence their consideration to
get pregnant; many factors underlie their decision
(Craft, Delaney, Bautista, & Serovich, 2007; Duggan et
al., 1999; Richter, Sowell, & Pluto, 2002). Factors such
as family support, cultural and societal factors also
contribute to their decisions (Sowell, Murdaugh, Addy,
Moneyham, & Tavokoli, 2002).
In many parts of Indonesia, the woman’s role as
homemaker and caregiver is a cornerstone of
society. This is even explicitly noted in the country’s
constitution and in the government’s main
development policy, which states that women’s
participation in the development process must not
conflict with their role in improving family welfare
and the education of the younger generation, and it
includes a role as wife and mother among women’s
duties (Andajani-Sutjahjo, Manderson, & Astbury,
2007). Although women are viewed by society as a
prominent person in the household, women who
are HIV positive must consider many issues when
contemplating motherhood.
Andajani-Sutjahjo et al, 2007 show that having
children is still highly valued by Indonesian society.
For HIV-positive women, however, it is a problematic
issue. While society appreciates women who have
children more than those who do not (Sowell,
Murdaugh, Addy, Moneyham, & Tavokoli, 2002),
society in general still stigmatises HIV-positive
people who are thinking of procreation (Ingram
& Hutchinson, 2000). In addition to society’s views
on HIV-positive women intending to get pregnant,
health care professionals also preclude discussion
about reproductive issues to these women (Ko &
Muecke, 2005a, , 2005b; Richter, Sowell, & Pluto, 2002;
Silva, Alvarenga, & Ayres, 2006; Wesley et al., 2000).
Some practices by health care professionals gave
the impression that reproductive issues, particularly
pregnancy, are excluded from consultation hours.
Continual prescription of the use of condoms by
these professionals worked indirectly as silent
preclusion of discussion about the possibility of
having children. People living with HIV indicated
that health care workers were not willing to discuss
reproductive options with them. Wesley et al (2000)
found that HIV-positive women reported negative
reactions toward health care providers as they were
constantly emphasising the importance of HIVpositive status in reproductive decision-making. The
women felt that the health care workers viewed them
as the virus rather than holistically as a woman with
the chance to bear children (Wesley et al 2000).
Pregnancy decisions among HIV-positive women
depend not just on their HIV-status, but also on
the support from their family, spouse and relatives
(Bedimo, Bessinger, & Kissinger, 1998; Ko & Muecke,
2005a, , 2005b) This support is intimately linked with
the concerns of positive women for the future of their
children once they, the mothers, become ill or die
(Ko & Muecke, 2005a, 2005b; Richter, Sowell, & Pluto,
2002; Rutenberg, Biddlecom, & Kaona, 2000; Wesley
et al., 2000). They were also significantly concerned
177
Social & Behavioral
Factors Influencing Pregnancy Decision-Making of
HIV Positive Women in Jakarta, Indonesia
Social & Behavioral
that the child left behind could have contracted HIV
and were aware of the nursing and care required
by children living with HIV. They were concerned
whether other caregivers would be able to provide
such care. That is why when these women were asked
about who would take care of their children when
the mother falls sick or dies, they required support
from parents, siblings and spouse (Richter, Sowell, &
Pluto, 2002).
HIV-positive women can justify their intention to get
pregnant in several ways, despite the risk of vertical
transmission. Several studies (Kirshenbaum et al.,
2004; Ko & Muecke, 2005a, 2005b; iegel & Schrimshaw,
2001) identified some justifications which play
important roles in women’s decision-making
about becoming pregnant. Mostly, the justification
appeared to address the women’s concern about
having an HIV-infected child by offering reasons
why they thought they would give birth to a healthy
baby. The justifications were: the experience of other
HIV-infected women having healthy babies; religious
beliefs; having confidence in their antiretroviral
treatment (ART) to improve their health status; and
their ability to raise a child in future after quitting
drug abuse. These women also believed that ART
improved their prospects of having a healthy baby.
A recent study examined intentions to have children
among HIVpositive men and women (Paiva et al.,
2007). The results revealed that the desire to have
children was associated with younger age, gender
(male), marital status (married or single), higher level
of education, being employed, and higher income.
The results are comparable with the outcomes
of international (Western) studies on pregnancy
motivation among HIV-positive women (Siegel
& Schrimshaw, 2001; Sowell, Murdaugh, Addy,
Moneyham, & Tavokoli, 2002). The study results show
that the characteristics of women who deliberately
had become pregnant after knowing their HIVpositive
status were of a younger age, had increased
motivation for childbearing, decreased perceived
threat of HIV, decreased HIV symptomatology, higher
traditional gender role orientation, and greater
avoidance coping. Although these women viewed
HIV as a threat to themselves and their babies, (ART)
such as zidovudine and nevirapine helps them keep
the virus under control.
Improved medical technology such as elective
178
caesarean section and drugs such as zidovudine and
single-dose nevirapine can now play a positive role
in the reproductive decisions of women infected
with, or at risk from, HIV. These facts influence HIVpositive women in weighing the risks and benefits of
having children (Duggan et al., 1999; Guay et al., 1999;
Siegel & Schrimshaw, 2001; Sowell, Murdaugh, Addy,
Moneyham, & Tavokoli, 2002). Women also gave
consideration to their CD4 count before deciding
to have a child at that time (Bedimo, Bessinger, &
Kissinger, 1998).
It is critical for health care workers to better
understand the factors that influence women’s
decisions to get pregnant after being diagnosed
as HIV positive because the number of HIVpositive
women and their needs for reproductive counselling
are increasing. Until now, there has been very little
research assessing reproductive decision-making for
HIV-positive women in Indonesia. Thus, a small study
was conducted in a clinical setting to identify factors
that significantly influence HIV-positive women’s
intention to get pregnant. Potential factors thought
to influence reproductive decision-making included
demographic characteristics, attitude, social norms,
and perceived behavioural control. Pokdisus
AIDS FKUI (Special Working Group on AIDS, Cipto
Mangunkusumo Hospital) was selected as the study
site because it offers a wide service to people living
with HIV and AIDS in Jakarta. Around 102 women
voluntarily enrolled as respondents in answering
a self-structured questionnaire developed from
extensive literature readings.
Discussion
Women who participated in this study were
predominantly young, with higher education, married
or had been married, and described themselves as fulltime housewives. These women were selfreportedly
sexually active, and able to become pregnant. Based
on their self-report, they were infected with HIV by their
husband sexually. The number of HIV status disclosure
is high due to the presence of family members or
referent (or significant) people during the women’s
voluntary testing and counselling and therapy. The
participants of this study showed that they intended
to get pregnant, despite being HIV positive.
Attitudes towards pregnancy are expressed
negatively by the participants, but attitudes to
particular activities when pregnant are rather
In multiple linear regression, attitude, social norms,
and perceived behavioural control were significantly
associated with the intention to get pregnant.
Women who have higher behavioural beliefs to
pregnancy were more likely to report an intention
to get pregnant. This suggests that reproductive
decision-making while being HIV positive is
significantly influenced by personal beliefs. One
possible explanation for this finding is that data were
collected amongst individuals who have historically
held traditional beliefs about women and pregnancy.
When assessing attitudes of these women by the
way they think or the way they feel, items of affective
and cognitive dimension show that they significantly
influence women’s intent to get pregnant. This
finding is supported by other research showing that
affective and cognitive measures of attitude are
related to behaviour (Conner & Norman, 2005).
Subjective norms significantly showed association
with intent to get pregnant. For these HIV-positive
women getting support from the most important
people in their lives and support from their society are
both necessary for them when they are considering
whether or not to get pregnant. The result suggests
that these women assume that they will gain support
from their referent people when making such a
decision. They also believe that they will receive
approval from the community when they decide to
get pregnant, despite their HIV-positive status.
Some findings of non-HIV-related factors to
reproductive decisions in HIV-positive women have
been reported in other countries. Studies in Taiwan
reveal that self-knowledge of HIV status had limited
influence on decision-making about childbearing
(Ko & Muecke, 2005a). In addition, women in many
societies still view motherhood as a source of selfexpression and self-esteem. That traditional belief can
give rise to women longing for children, even though
they are HIV positive (Ingram & Hutchinson, 2000;
Richter, Sowell, & Pluto, 2002; Sowell, Murdaugh,
Addy, Moneyham, & Tavokoli, 2002).
Some studies suggested that the importance of a
partner’s desire for a child may influence a woman’s
intent to get pregnant. Previous research into
HIV-positive women have shown that the desires
and needs of the husband or partner are another
significant piece of the puzzle for a woman in her
reproductive decision-making (Kirshenbaum et
al., 2004; Kline, Strickler, & Kempf, 1995; Siegel &
Schrimshaw, 2001). Support from family, friends
and professional health workers also play a role for a
woman considering pregnancy. A number of studies
have revealed that pregnancy intention among
HIV-positive women increases when they have
support from these groups (Craft, Delaney, Bautista,
& Serovich, 2007; Kirshenbaum et al., 2004; Ko &
Muecke, 2005a, , 2005b; Wesley et al., 2000).
Perceived behavioural control (PBC) also showed
significant association with intent to get pregnant.
However, the association has negative rather than
positive links to compare to the other two predictors.
It is likely that the higher the women’s perceived
control towards pregnancy while being HIV positive,
the lower the intention to get pregnant. Though
many studies show that PBC is the best predictor
for intention towards behaviour, the findings of this
study shows a contrary result. This might be caused
by the weak association of the items under PBC
towards intention to get pregnant.
None of the demographic characteristic variables
were significant predictors in cross-tabulation
model. This finding is supported by others. Ingram
et al (2000) found that psychosocial and cultural
factors, especially those involving husband or sex
partner, were important for HIV-positive women
in reproductive decisionmaking. Siegel et al (2001)
reported that a husband or partner wanting a child
was a factor underlying a woman’s decision to have
a child. In a more recent report by Craft et al. (2007),
pregnancies after HIV were found to be associated
with procreative inclination.
Caveats
The findings of this study should be considered within
the context of several methodological limitations.
One limitation of this study lies in the sampling
procedure. Women who selected to enroll in the study
179
Social & Behavioral
positive. The women assume that they will receive
social support from their referent people. They also
assume that they will receive social approval from
the community when deciding to get pregnant while
being HIV positive. These women think that they
have control over pregnancy. Yet, at the same time
they think that pregnancy is the will of God. Their
reasoning is that they must do their best to perform
an action, as a believer, and let God do the rest.
Social & Behavioral
may differ from other women in a number of ways.
That is, they may be more open, more comfortable
with their HIV status or more connected to HIVrelated services. This suggests a possible selection
bias. A second limitation concerns the questionnaire
methodology, as this tool was author-derived and
had no comparison data for validity or reliability.
The tool may not have fully captured the social,
interpersonal or medical factors that influenced
decisions regarding pregnancy. Financial stress,
religious orientation and access to contraceptives
are additional factors that might be salient to
these women when they are making reproductive
decisions. However, none of these factors were
assessed in this study. Additional research is needed
not only to expand the validity and reliability of the
tool, but also to reveal additional factors which may
significantly influence the reproductive decisions of
HIV-positive women in Indonesia.
Conclusion
The results of this study indicate that HIV-positive
women are not different from non HIV-infected
women in regards to intention to get pregnant. This
significant issue needs to be taken into consideration
when health care workers counsel HIV-positive
women about reproductive decision-making. Health
care workers should recognise and appreciate that
their clients may be struggling with pregnancy-related
decisions. Concisely, the decision to get pregnant
or not by HIV-positive women is neither simple nor
influenced only by one factor. Factors significantly
associated with intent to get pregnant were women’s
attitude, perception of other important people to
them and the society, and the overall control they
perceived themselves to have over intention to get
pregnant. Accurate information on pregnancy and
the implications of HIV on pregnancy provided by
trained health care workers could be both helpful
and reassuring to HIV-positive women.
As further research is needed, health care workers who
provide care and services for HIV-positive women can
use these findings to identify women who intend to
get pregnant and accentuate the benefits and the risks
associated with pregnancy. In addition, health care
providers are required to incorporate the possibility
of these women of childbearing into their care
planning. Since many HIV-positive women and their
families consider motherhood an important part of a
180
woman’s life, it may not be sensible to expect these
women to use contraception or to make reproductive
decisions alone, without consulting and listening to
their husbands and family. A more rational aim for
health care providers is to help HIV-positive women
to learn how to continue fulfilling their caring and
nurturing roles while making decisions in their own
best interests
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Herke G Sigarlaki1
1
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Acta Med Indones. 2008 Jul;40(3):129-34
Indonesian Society of Internal Medicine
183
Social & Behavioral
Characteristics and Knowledge About HIV/AIDS
and Drugs Abuse Associated with Inmates Education
Level within Prison Populations in Singkawang,
West Borneo in 2006
Abstract
Aim: to identify the characteristics and knowledge of inmates within prison population in Singkawang city about HIV /AIDS and drugs
associated with their education level.
Methods: a cross-sectional study with 240 respondents was conducted in Singkawang City, West Borneo. The subjects were inmates
of-prison population. They were interviewed by co-assistant doctors who completed the questionnaire forms about various aspects of
knowledge about HIV/AIDS and drugs, including the application of standardized scales on subject characteristics. Data was prepared by
using Microsoft Excel! 2000 and all data were evaluated by univariate and bivariate analyses. The presentation will be shown in table.
Results: at the end of 2006, 91.25% respondents were male and mostly were Malay ethnic group. Moreover, 32.08% of them had formal
educational background of Senior High School. Approximately 83.33% of respondents had discovered their status of HIV / AIDS by
voluntary counseling and testing (VCT). Their level of knowledge about HIV/AIDS issue particularly that AIDS is caused by HIV was 90.42%.
Approximately 48.33% respondents agreed that the risk factor for drug abuse was living with a family member who had taken up smoking
and alcoholic consumption.
Conclusion: our data indicate that higher education level has better contribution to the better knowledge about HIV/AIDS and drugs.
Key words: HIV/AIDS, drugs, knowledge
Introduction
In Indonesia, mortality and morbidity rate caused by
HIV/AIDS has been increasing. There has been a steep
increase of HIV/AIDS infection in Indonesia. A report
indicated that there were 9 cases of HIV/AIDS in 1987
and it was further increased into 3515 cases in 2005.
However, since the reporting system in Indonesia has
not been well-standardized, the estimated number of
cases as abovementioned may not represent the true
number of cases.1 Currently, there are approximately
80,000 to 120,000 people living with HIV/AIDS in
Indonesia, which may denote the true number of
HIVI AIDS cases in Indonesia.2 Major risk factors of HIV
transmission include heterosexual contact (about
4203 cases) and the sharing injection by drug users
or IDUs (approximately 4088 cases).3 The western
free-sex culture has influenced our society life style
and consequently increases the risk factor of HIV
infection .4
Low education level may act as one of factors
that cause lack of knowledge about HIV/AIDS in
Indonesians population. It may become one of
shortcomings in preventing and solving the problem
of HIV/AIDS.5 People need to know about what HIV/
AIDS is, its symptoms, mode of HIV/AIDS transmission,
risk factors, preventions, and what they must do if they
have suspected symptoms of HIV/AIDS; therefore,
people can participate to help the government
programs of solving HIV/AIDS problems.
The aim for carrying out this research is to identify
the characteristics and knowledge of inmates within
prison population in Singkawang city about HIV/
AIDS and drugs associated with their education
level. Thus, there are several parameters to recognize
it as assigned in the questionnaire involving
subject characteristics, risk factors, way of HIV/AIDS
transmission, clinical manifestation, as well as the
available prevention and therapeutic measures.6-9
Methods
Target Respondents and Sampling Procedures
The analysis was based on previous study conducted
by The Department of Public Health, Faculty of
Medicine, the Indonesian Christian University. In
2006, an accidental sample of 240 inmates of prison
population in Singkawang City, West Borneo, were
185
Social & Behavioral
Characteristics and Knowledge About HIV/AIDS
and Drugs Abuse Associated with Inmates Education
Level within Prison Populations in Singkawang,
West Borneo in 2006
Social & Behavioral
interviewed by co-assistant doctors who completed
the questionnaire forms about various aspects of
knowledge about HIV/AIDS and drugs, including
the application of standardized scales on subject
characteristics (sex, age, education, ethnic group,
employment, marital status). This study was a
descriptive cross-sectional study.10,11
Evaluation of Knowledge About HIV/AIDS and Drugs
We evaluated ten various questions of HIV/AIDS
and drugs (five questions for each part), including:
prevention of HIV/AIDS; how to recognize the HIV/
AIDS status; unrelated mode of HIV/AIDS transmission;
the cause of AIDS; persons who can be infected by
HIV/AIDS; risk factor of drug abuse, degree of drug
dependence in preventing HIV/AIDS among drug
users; type of stimulant agents; type of drugs that
potentially cause addiction; and type of drugs with
white, clean and rough crystal appearance.12-14
The level of knowledge was categorized into
high, moderate, and low. We regarded the high
level of knowledge when inmates could give 9-10
correct answers. Moderate level of knowledge was
considered when they could provide 6-8 correct
answers; while low level of knowledge was regarded
when they could only provide < 5 correct answers.
Data Preparation and Analysis
Data were processed automatically by using Microsoft
Excell 2000 through editing, coding, and tabulating
process. All data were evaluated by univariate End
bivariate analyses to identify subject characteristics
and distribution of subjects’ knowledge associated
with their education level.8,9
Results
Univarlate Analysis
Most respondents were male, i.e. 219 respondents
(91.25%). Among them, 103 were Malay (42.92%).
Approximately 114 respondents (47.50%) were at age
group of 21-30 years old. Moreover, 77 respondents
(32.08%) were Senior High School graduates, 125
respondents (52.08%) were entrepreneur in private
sectors; and 127 respondents (52.9%) were married.
Approximately 48.33% respondents pointed healthy
lifestyle and consumption of high nutrient food
as the way of HIV/AIDS prevention. In addition,
83.33% of respondents had known about voluntary
counseling and testing (VCT). Mosquito bite had
186
been assumed to be unrelated to mode of HIV/
AIDS transmission in 91.67% respondents;-while
90.42% respondents regarded virus as the cause of
HIV/AIDS. About 81.25% respondents agreed that
people who had unprotected sex would have high
risk of transmission. Moreover, 48.3 3% respondents
stated that the risk factor of drugs abuse including
living with a family member who had taken up
smoking and alcoholic consumption; while 53.33%
respondents regarded addiction as the most severe
degree of drug dependence in preventing HIV/
AIDS among the drug users., Cocaine as stimulant
agents was assumed by 56.25% respondents and
91.67 respondents regarded heroine as the type of
drugs that potentially cause addiction. Furthermore,
56.25% respondents stated that cocaine as the type
of drugs with typical distinctiveness of white, clean,
clear, and rough crystal appearance.
Our study found that 52.08% respondents had
moderate levels of knowledge about HIV/AIDS and
drugs. It may have an important role since HIW/AIDS
transmission has been increasing every year. Hence,
Most of respondents had formal education
background of Senior High School and properly
known how to prevent HIV/AIDS with total number
of 17.08% respondents; while 29.12 % respondents
had known about VCT (Voluntary Counseling and
Testing), i.e. they had known how to recognize HIV/
AIDS. Moreover, 30.42% respondents had answered
that mosquito bite was not related to the mode of
transmission of HIV infection. Approximately 90.42%
respondents considered virus as the cause of HIV/
AIDS. The higher level of knowledge they had, the
easier for us to prevent HIV/AIDS. In addition, 48.33%
respondents stated that the risk factor for drug abuse
was living with a family member who had taken up
smoking and alcoholic consumption.
Addiction was the most severe degree of drug
users as agreed by 53.33% respondents who had
formal education background of Senior High School.
About 22.08% respondents had provided correct
answer for identifying the characteristic of cocaine;
while 17.92% had moderate level of knowledge
about HIV/AIDS and drugs.
Discussion
This study was a cross-sectional study; therefore, it
is not able to explain causative relationship of the
condition ,described above. The study had only
demonstrated the percentage of data. Further studies
are still necessary as comparisons to this study.
Most of respondents were males with total number of
219 respondents (91.25%). It demonstrated that most
of inmates who came to elucidation at social activity
in Singkawang city were male. In addition, it also
indicated that there were more male inmates than
female within prison population in Singkawang City.
The result showed that the majority of respondents,
i.e. 103 respondents were Malay (42.92%), and 114
respondents (47.50%) were at 21-30 of age. It can
be concluded that most of inmates within prison
population in Singkawang were Malay and at the age
between 21-30 years old.
we hope that through such level of knowledge about
HIV/ AIDS, the society could prevent the transmission
of disease and they may put effort of seeking medical
treatment in the first place.
Concerning the education level, most of respondents
were Senior High School graduates, i.e. 77 respondents
(32.08%). More than 50% of inmates in Singkawang
had finished their primary 9 years of education in
187
Social & Behavioral
Bivariate Analysis
Social & Behavioral
2006. It indicated that their awareness of importance
in education was fairly good. Their society also had a
habit of sending their children to higher education
level, in addition to their local government financial
support for primary education in Singkawang city.
(And it is also their highest society habit to send
their children to private schools, despite the subsidy
from local government unit in primary education at
Singkawang city).
For their living, most of respondents were
entrepreneurs in private sectors, with total number
of 125 respondents (52.08%) and 127 respondents
(52.92%) were married.
Approximately 48.33% respondents agreed answer
tat the way of preventing HIV/AIDS is by having a
healthy lifestyle and consuming high nutrient food.
It sows that the level of knowledge about HIV/
AIDS prevention was very low. However, 91.67%
respondents considered that HIV/AIDS transmission
was not correlated to mosquito bites. It means
they had known that the transmission of HIV/AIDS
was through sharing needles and unfaithful sexual
188
behavior. About 90.42% respondents agreed that
the cause of HIV/AIDS is virus. It shows that their
knowledge about the cause of HIV/AIDS was good.
Moreover, most of respondents (83.33%) had known
about the procedure of voluntary counseling and
testing (VCT).
Majority of respondents had a high level of
knowledge about people who had high-risk of HIV/
AIDS infection. It was demonstrated by 81.25%
respondents who had agreed that people with highrisk sexual activity (unprotected sex) have high-risk
of HIV/AIDS transmission.
About 48.33% respondents said that the risk factor
of drug abuse was living with a family member who
had taken up smoking and alcoholic consumption.
Approximately 53.33% respondents agreed that
addiction was the most severe degree of drug
users. Most of inmates had been familiar with various
type of drugs which are demonstrated by 56.25%
respondents regarded cocaine as the type of stimulant
Social & Behavioral
189
Social & Behavioral
agents and 91.67% agreed that heroine as the type
of drugs that may potentially cause addiction; while
56.25% respondents considered cocaine as the type
of drugs with distinct white, clean and rough crystal
appearance.
There is a difference between our study and the study
in Vietnam. Our study only describes the association
between formal education with the knowledge about
HIV/AIDS and drugs; while the study in Vietnam
describes about formal education and its correlation
to knowledge and behaviors.
The respondents have moderate level of knowledge
about HIV/AIDS as shown in 52.08% respondents.
Conclusion
Most of respondents had formal education
background of Senior High School who had already
gained a good knowledge about HIV/AIDS prevention
(17.08%); while 29.12 % respondents had known
about VCT (Voluntary Counseling and Testing), which
means that they have the knowledge about how to
recognize HIV/AIDS status.
This cross-sectional study demonstrates that the
respondents have moderate level of knowledge
about, HIV /AIDS and drugs as shown in 52.08%
respondents; while 17.92 % respondents have had
Therefore, we conclude that higher education
contributes to better knowledge about HIV/AIDS and
drugs.
In addition, they gained that HIV/AIDS transmission
does not correlated to mosquito bite with the total
answers of 30.42%. Furthermore, 90.42% respondents
also agreed that virus is the cause of HIV/AIDS. The
higher the level of knowledge they have, the easier
for us to prevent HIV/AIDS. Subsequently, 48.33%
respondents stated that the risk factor of drug abuse
was living with a family member who had become
smoker or alcoholic.
References
1.
Ditjen P2MPL Departement of Health Indonesian Republic.
Statistik kasus HIV/AIDS di Indonesia dilaporkan s/d Maret
2006. Available from: http://www.lp3y.org/content/AIDSI sti.
htm.
2.
Effendy N. Perawatan kesehatan masyarakat. Jakarta: EGC
Press; 1995. p. 1-4.
3.
Fauci AS, Lane HC. Human immunodeficiency virus disease:
AIDS and related disorders. In: Kasper DL, Braunwald E, Fauci
AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s principles
of internal medicine. 161 ed. New York: McGrawHill. 2005. p.
1076-82.
4.
Scaiway T. Young men and HIV. Jakarta: UKI Press; 2002.
Addiction is the most severe degree of drug
user as shown by 53.33 % respondents who had
Approximately 22.08 % had given correct answers for
identifying characteristic of cocaine; while 17.92%
respondents had moderate level of knowledge about
HIV/ AIDS and drugs.
5.
Djauzi S, Djoerban Z (editor). Penatalaksanaan infeksi HIV di
pelayanan kesehatan dasar. 21 ed. Jakarta: FKUI Press; 2003. p.
3-23.
6.
HIV/AIDS. Buku ajar ilmu penyakit dalam. Jilid 1. 31’ ed. Jakarta:
FKUI Press; 2001. p. 543-50.
7.
HIV/AIDS. Buku ajar ilmu penyakit dalam. Jilid 1. 4’h ed. Jakarta:
FKUI Press; 2006.
8.
HIV/AIDS. Buku ajar ilmu penyakit dalam. Jilid 3. 4`h ed.
Jakarta: FKUI Press; 2006.
9.
Nursalam, Nurs M, Kurniawati DN. HIV/AIDS. Jakarta: Salemba
Medika Press; 2006.
Our study has been compared to other crosssectional
study which investigated various sexual behavior and
knowledge about HIV among urban, rural, and minority
residents in Vietnam 2001. The study has concluded
that low prevalence of reports of individuals having
had sex with sex workers and partners other than
their spouse may explain the low rates of HIV infection
among the heterosexual population; in contrast to
the high rates of HIV infection found among injected
drug users. The positive association between having
extramarital partners and being a younger generation
suggests that the tendency to have more sexual
partners may increase in the future. If this happens,
the potential for HIV infection to be spread through
heterosexual sex activity will increase.15
10. Sigarlaki HJO. Epidemiologi. Jakarta: Infomedika Press; 2003.
p. 45-52.
190
11. Sigarlaki HJO. Metodologi penelitian kedokteran dan
kesehatan. Jakarta: Infomedika Press; 2003. p. 42-75, 89-99.
12. Mengenal jenis dan efek buruk narkoba. 1st ed. Jakarta:
Visimedia Press; 2006.
13. Mencegah terjerumus narkoba. 1”ed. Jakarta: Visimedia Press;
2006.
14. Wresniwiro. Narkoba musuh bangsa. 1st ed. Jakarta: Mitra
Bintimas Press; 2006.
15. Bui Thang D, et al. Cross-sectional study of sexual behavior
and knowledge about HIV among urban, rural and minority
residents in Vietnam. Bulletin of the World Health Organization.
2001;79(l).
Social & Behavioral
Barriers for Introducing HIV Testing
among Tuberculosis Patients in Jogjakarta,
Indonesia: A Qualitative Study
Yodi Mahendradhata1,2
Riris Andono Ahmad1
Pierre Lefèvre2
Marleen Boelaert2
Patrick Van der Stuyft2
1
Department of Public Health, Faculty of Medicine, Gadjah Mada University,
Jogjakarta, Indonesia.
2
Epidemiology and Disease Control Unit, Public Health Department, Institute
of Tropical Medicine, Antwerp, Belgium.
BMC Public Health. 2008 Nov 12;8:385
BioMed Central
191
Abstract
Background: HIV and HIV-TB co-infection are slowly increasing in Indonesia. WHO recommends HIV testing among TB patients as a key response
to the dual HIV-TB epidemic. Concerns over potential negative impacts to TB control and lack of operational clarity have hindered progress. We
investigated the barriers and opportunities for introducing HIV testing perceived by TB patients and providers in Jogjakarta, Indonesia.
Methods: We offered Voluntary Counselling and Testing (VCT) to TB patients in parallel to a HIV prevalence survey. We conducted in-depth
interviews with 33 TB patients, 3 specialist physicians and 3 disease control managers. We also conducted 4 Focus Group Discussions (FGDs) with
nurses. All interviews and FGDs were recorded and data analysis was supported by the QSR N6® software.
Results: Patients’ and providers’ knowledge regarding HIV was poor. The main barriers perceived by patients were: burden for accessing VCT and
fear of knowing the test results. Stigma caused concerns among providers, but did not play much role in patients’ attitude towards VCT. The main
barriers perceived by providers were communication, patients feeling offended, stigmatization and additional burden.
Conclusion: Introduction of HIV testing among TB patients in Indonesia should be accompanied by patient and provider education as well as
providing conditions for effective communication.
Introduction
Indonesia is critical to the global tuberculosis (TB)
control efforts and increasingly important in the
global HIV control efforts. The country ranks third in
the world for TB burden [1]. The number of reported
AIDS cases has increased by 15 fold in the past ten
years [2]. The rapid increase of new HIV infections
in Indonesia makes the epidemic one of the fastest
growing in Asia, even though the aggregate national
prevalence is as low as 0.16% [3]. By the end of 2007,
there were 296 Voluntary Counselling and Testing
(VCT) clinics throughout Indonesia, in addition to 153
hospitals which provide free antiretroviral treatment
[3]. Patients with HIV-TB co-infection are appearing in
hospitals and jails across several provinces and TB is a
leading opportunistic infection among AIDS patients
[4]. These trends suggest a potential of a dual HIV-TB
epidemic, which many other developing countries,
particularly in Sub-Saharan Africa are already facing.
WHO Interim Policy on HIV-TB recommends HIV
testing among TB patients as an entry point for
integrated HIV-TB care and surveillance [5]. However,
scaling-up of this policy has been lagging [6].
Concerns over stigmatization which may generate TB
patients unwillingness to use HIV associated services
(with potential negative impact on TB case detection)
and lack of detailed operational guidelines are among
the important barriers [6,7].
Additionally, there is an ethical debate surrounding
HIV testing among TB patients, particularly with
regard to the unlinked anonymous testing method,
in view of the improved prospects for HIV/AIDS
treatment [8]. This led to linked confidential testing
through an ‘opt in’ approach, which has been offered
in Voluntary Counselling and Testing (VCT) centres
[9]. More recently, WHO encouraged the adoption
of provider-initiated linked confidential testing and
counselling (PITC) [10]. In contrast to VCT, PITC is
based on an ‘opt out’ approach in which the clinician
initiates counselling when an individual is seeking
medical care with signs or symptoms compatible
with HIV infection [9].
Ultimately, decisions about how to implement
HIV testing in TB patients, should be guided by an
understanding of issues surrounding HIV testing
among TB patients from the local stakeholders’
perspectives [11]. Studies on groups other than TB
patients suggest that knowledge, fear and access
may constitute important barriers to HIV testing
[12-14]. This study aimed to shed light on the issue
through investigating the barriers for introducing
HIV testing perceived by TB patients and providers in
Jogjakarta, Indonesia.
193
Social & Behavioral
Barriers for Introducing HIV Testing
among Tuberculosis Patients in Jogjakarta,
Indonesia: A Qualitative Study
Method
Social & Behavioral
Study context
Jogjakarta province is located in the central part
of Java island. It is divided into five districts, has
3.2 million inhabitants and covers an area of 3,185
square km. The province’s primary care network
consists of around 650 private practices and 117
public community health centres staffed with
doctors, midwives and nurses. These first line services
are backed up by 9 public hospitals and 24 private
hospitals. The backbone of NTP’s DOTS (Directly
Observed Treatment, Short-course) programme in
Jogjakarta province comprises a network of the 117
public health centres, 5 chest clinics and 18 public
and private hospitals.
HIV prevalence among the general adult population
in Jogjakarta province is 0.15–2.0% [15]. It is much
higher among high-risk groups, e.g. sex workers [4.6
(3.6–6.4)%]; injecting drug users [39.3(29.0–52.7%)].
VCT services have been established in four hospitals
and one NGO clinic. The standard procedure in these
VCT services, in accordance to WHO guidelines for
settings with HIV prevalence = 10% [16], requires three
HIV tests (two rapid and one Enzyme Immunoassays
test). Patients would have to return the next day to
obtain all three test results. These VCT services are
free of charge for all, including TB patients, through
financial support from the Global Fund to fight AIDS,
TB and Malaria.
Study design
The study was conducted in parallel to a HIV
prevalence survey among TB patients carried out
between April and December 2006. The survey
targeted TB patients attending all (88) public and
private DOTS services in three out of five districts
in the province. TB patients in participating health
facilities were offered unlinked anonymous HIV
testing for survey purpose and additionally free
services of four hospital-based VCT centres. Nurses
provided patients with standardized information
on HIV and VCT services aided by a brochure which
was subsequently given to the patient. If the patient
expressed interest, nurses made an appointment
with a VCT centre and provided an incentive to cover
Consenting
registered TB
patients (N=764)
Not interestes for
VCT (N=633)
Category 1.
Not accepting
unliked
anonymous
(N=6)
Category 2.
Accepted
unliked
anonymous
testing
(N=627)
Category 3.
No VCT
attendance
(N=52)
Category 4.
VCT
attendance
(N=79)
Enrolled = 6
Enrolled = 16
Enrolled = 2
Enrolled = 9
Figure 1
Patient flow.
194
Interested for VCT
(N=131)
The patients were asked whether they would
be willing to be recruited for follow up in-depth
interviews. We grouped the patients who accepted
into four groups: (1) patients who refused unlinked
anonymous testing and expressed no interest in
VCT; (2) patients who accepted unlinked anonymous
testing and expressed no interest in VCT; (3) patients
who expressed interest, but did not attend VCT; and
(4) patients who attended VCT. Among 1269 patients
offered unlinked anonymous testing and VCT
service during the parallel survey, 764 accepted to
be interviewed. Figure 1 presents the distribution of
these consenting patients by the 4 patient categories.
We aimed to purposively sample eight patients
within each group, keeping in mind the type of
health facility attended and additionally age, gender,
education and urban/rural residency. Appointments
were made by nurses for the indepth interviews of
selected patients.
We interviewed 33 patients: 6 patients for group 1;
16 patients for group 2; 2 patients for group 3; and 9
patients for group 4. We faced difficulties recruiting
patients for group 3 because the interview was
perceived as a blaming attempt since they had
received an incentive to cover transport to VCT, but
had not attended. The large number of patients in
group 2 was due to the need to increase the number
of interviews to make up for the limited information
collected from the first 8 respondents related to their
very poor knowledge about HIV/AIDS. Patients were
interviewed on the basis of an in-depth interview
guide on why they were interested or not interested
in VCT and probed for factors that hinder or support
VCT uptake, e.g. knowledge, attitudes, information
given by health providers regarding VCT.
Barriers preventing DOTS services providers to offer
VCT services were also explored. We investigated
nurses’ perceptions through four Focus-Group
Table 1: Characteristics of enrolled TB patients
Patients' Characteristics
Patients' category*
Total N (%)
Group 1 N (%)
Group 2 N (%)
Group 3 N (%)
Group 4 N (%)
Gender
Male
Female
4 (66.7)
2 (33.3)
8 (50.0)
8 (50.0)
1 (50.0)
1 (50.0)
5 (55.6)
4 (44.4)
18 (54.5)
15 (45.5)
Age group
15–19 years old
20–29 years old
30–39 years old
40–49 years old
> 49 years old
0 (0.0)
2 (33.3)
0 (0.0)
0 (0.0)
4 (66.7)
0 (0.0)
9 (56.3)
8 (31.3)
2 (12.5)
0 (0.0)
1 (50.0)
1 (50.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (11.1)
4 (44.4)
1 (11.1)
3 (33.3)
0 (0.0)
2 (6.1)
16 (48.5)
6 (18.2)
5 (15.2)
4 (12.1)
Education
Primary
Secondary
Tertiary
1 (16.7)
3 (50.0)
2 (33.3)
2 (12.5)
11 (68.8)
3 (18.8)
0 (0.0)
0 (0.0)
2 (100.0)
2 (22.2)
4 (44.4)
3 (33.3)
5 (15.2)
18 (54.5)
10 (30.3)
Married
Yes
No
4 (66.7)
2 (33.3)
11 (68.8)
5 (31.3)
1 (50.0)
1 (50.0)
5 (55.6)
4 (44.4)
21 (63.6)
12 (36.4)
Health facility type
Public
Private
3 (50.0)
3 (50.0)
11 (68.8)
5 (31.3)
2 (100.0)
0 (0.0)
8 (88.9)
1 (11.1)
24 (72.7)
9 (27.3)
6 (100.0)
16 (100.0)
2 (100.0)
9 (100.0)
33 (100.0
TOTAL
*Patients category:
• Group 1. Not accepting unlinked anonymous and not interested for VCT.
• Group 2. Accepted unlinked anonymous but not interested for VCT.
• Group 3. Accepted unlinked anonymous, expressed interest but did not attended VCT.
• Group 4. Accepted unlinked anonymous and attended VCT.
195
Social & Behavioral
transport expenses to the centre. Out of 1269 TB
patients whom were offered unlinked anonymous
testing during the survey, 989 (77.9%) accepted [17].
The HIV prevalence was 1.9% (95% CI 1.6–2.2%) [17].
Out of these 989 patients, 133 (13.4%) expressed
interest in VCT but only 52 (39.1%) subsequently
attended VCT.
Social & Behavioral
Discussions (FGDs) sampling the different health
facility types: (1) urban health centres; (2) rural
health centres; (3) private hospitals; and (4) public
hospitals and chest clinics. Within each group,
we purposively selected nurses who were most
involved in the offering HIV testing among TB
patients and represented facilities with variation of
patients’ interest rate toward HIV testing. Each group
consisted of eight to nine nurses. We finally carried
out three in-depth interviews with all the specialist
physicians providing DOTS services in public and
private hospitals and with the three district disease
control managers.
The in-depth interviews and FGDs were conducted
by the first and second author.
Data analysis
We recorded and fully transcribed all in-depth
interviews and FGDs. Data analysis was supported
using the QSR N6® software (QSR International
Pty. Ltd., Melbourne, Australia, 2002). The analysis
was inductive which implies that categories of
analysis were not imposed a priori on the data but
are identified through the analysis process [18].
Transcripts imported into the software database
were scrutinized to identify emerging and recurrent
themes and a codebook was progressively established
and structured. Text units were coded systematically.
Coding frequency permitted to identify key issues
and trends regarding perceptions of patients and
providers about barriers to HIV testing.
Ethical issues
We safeguarded confidentiality of patients’ serostatus
by unlinking HIV test results from our patients’
identities. Informed consent was obtained from all
respondents prior to data collection. All collected
data were kept anonymous. Ethical approval for the
qualitative data collection and the HIV-TB prevalence
survey was given by the ethical review committee
of the Faculty of Medicine, Gadjah Mada University,
Indonesia.
Results
Patients’ characteristics
Table 1 presents the characteristics of the interviewed
patients’ for the four categories. There were slightly
more males then females among the patients. In
general, they were predominantly aged between
20–40 years old, married, had secondary education
196
and were offered VCT services by a public care
provider. The groups’ characteristics were in general
similar with the exception of group 1 having slightly
more old patients and group 4 having more patients
attending public health facilities.
Factors influencing patients’ interests in VCT
Many of our respondents (22) were not interested to
attend VCT regardless of gender, age, education and
marital status. Most patients (24) had no negative
feeling towards the HIV test offer, though some (9)
clearly felt offended:
Table 2: Patients' perceptions and interest for VCT
Patient's perception
At risk of being infected
VCT entails benefits
HIV patients are stigmatized
Fear of knowing test result
Access to VCT is a burden
Interested for VCT
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
majority
minority
roughly half
small minority
roughly half
minority
small minority
vast majority
minority
vast minority
Frankly, that time I was offended. From the
beginning, it was already explained that HIV is
transmitted by this and that, not all drug users get
it, also not all ‘others’ [risk groups] get it. And then
all the sudden they offered me HIV test? 23-yearold, male, university student, attended VCT
Knowledge of many respondents (11) on HIV was
poor, ranging from those who had never heard of
HIV to those who knew little. Patients with limited
knowledge were less interested in VCT:
The problem is I don’t even know what HF [HIV] is.
Is it a new disease? I am just a lay person, so I don’t
know. It was my son who replied. [I told him] you
should respond because you are the one who can
answer. 52 year-old, male, employee, not interested
in VCT
Well what can I say? That HIV is not scary. It’s just
another disease. It can be cured. 29-year-old, female,
employee, not interested in VCT
Misconceptions regarding transmission of HIV/AIDS
were common:
You can get infected through having a [sexual]
relationship or through drugs or through smoking
cigarettes, that’s all I know. I heard it before
from stories, you know, on TV. 26-year-old, male,
unemployed, attended VCT
Table 2 summarizes the relations between main
patients’ perceptions and VCT interest. Many patients
(16) did not report to perceive themselves at risk, or
simply did not know enough to attribute risk (10):
It’s just for a test. It’s not because one gets TB that
one will get HIV. I’ve never done anything [wrong].
So I don’t mind and I am also looking for a new
experience. I am confident that the result will be
non-reactive. No worries whatsoever. I am sure,
Insya Allah [God’s willing], as the doctor already
know, that I won’t get it. I imagine if one gets it. Oh
my God! 37-year-old, male, employee, attended VCT
I mean usually those who get HIV are those who
like to go out at night, they like to...well, like
commercial sex workers, they’re like that, so they
must get it. I never go out at night. I hardly leave
my house. How can I get HIV? 29-year-old, female,
employee, attended VCT
A few patients (7) accepted that they could be at risk
and were interested in VCT:
I’ve never done anything wrong [risky], or had a
[sexual] relationship with someone with HIV. I’ve
never received blood transfusion, never. I don’t
believe I can get HIV but, there’s a possibility I
get it because of TB, they say that can make you
get infected easily. 45-year-old, male, construction
worker, attended VCT
No, I was already told [by the health worker]
that from ...from the lungs it can lead to HIV. So I
already knew before hand. 24-year-old, female, selfemployed, attended VCT
Nearly half of the patients (16) perceived a certain
benefit of HIV testing, regardless of whether they
reported to perceive themselves at risk or not. Many
of these (9) expressed interest towards VCT:
Well, to be able to know [whether I get] AIDS or
...HIV. I was not surprised [to be offered HIV testing].
I wanted to be examined to see if I had other diseases.
26-year-old, male, unemployed, attended VCT
Some patients (10) perceived some stigmatization
towards people living with HIV in the society.
Others (8) did not perceive stigmatization, while the
remaining participants (15) had no opinion. Most
of those who perceived stigmatization (6) however
were interested in VCT:
[They are] afraid to get infected, yes. Also afraid of ...
what else...Well, it’s a shameful and horrible disease.
It’s terrifying. So I would be afraid to be isolated, to
be treated as someone infectious, as someone who
has a pathetic disease. If I can, I will just avoid such
disease. 29-year-old, female, attended VCT
Well, the problem is AIDS is... Well, it is a shameful
disease. I don’t know... The problem is most people
who get AIDS are those who do wrong things.
People where I live, if they know, they will avoid you
immediately. 17-year-old, female, student, attended
VCT
Some patients (5) feared knowing the HIV test result
and were not interested in VCT, or initially expressed
interest, but eventually changed their mind:
Why did it go that far? Saying HIV was like this and
that. That made me scared. It’s about psychology,
I am sure I don’t have HIV, but I am not mentally
ready. It’s enough that I got TB. If for instance I had
to be tested for something like that [HIV], it could
make things more complicated with so many
problems...Oohhh! 23-year-old, male, student, not
interested in VCT
Table 3: Nurses' perceptions of barriers to introduce HIV testing among TB patients*
Perception
'Hard' patients
Additional burden
Patients offended
Stigmatization
Lack of facility
Communication difficulty
Health centres
Hospitals and chest clinics
Rural
Urban
Public
Private
+/+
+
+/-
+/+/+++
+/-
+
++
++
+++
+/++
++
++
++
++
+
+++
* "+++" = critical; "++" = very important; "+" = "important"; "+/-" = less important; "-" = negligible
197
Social & Behavioral
I would imagine, that people who get infected by
HIV are those who keep changing partners. If one
doesn’t change partners and does not use illegal
drugs, then probably [he/she] can’t get infected.
45-year-old, male, construction worker, attended
VCT
Social & Behavioral
If they take my blood again, then they will test it,
then if it turns out that I have that disease, it’s like
being struck on the head, it’s a mental burden. What
I am afraid of is that there is no cure yet, you die
because of HIV. So if there’s no treatment you will
just die. 23-year-old male, student, initially expressed
interest, but did not attend VCT
A number of patients (8) also perceived burden for
accessing and utilizing VCT. Most of these (6) were
not interested in VCT.
The process would become too cumbersome. When
I think about it, it will just make the process longer
and complicated. My intention to seek treatment
was just to get my coughs cured. 25-year-old, male,
self-employed, not interested in VCT.
Well, at that time I thought, if they can do it at
that moment, I wouldn’t mind. I thought it would
take too much time. [I asked] how I would know
the result. [They said] if I wanted to know I have to
go there. How can I manage the time? 51-year-old,
male, employee, not interested in VCT.
Nurses’ perceptions
Table 3 depicts the distribution of main issues
perceived by nurses across different type of health
facilities. Most nurses considered their knowledge of
HIV-TB insufficient:
At the least, the lab technician, TB worker, nurse
and doctor should know about the HIV issue
comprehensively. Sometimes we go for training and
bring home materials, but we don’t really read them.
There are patients who really need information on
what is the relevance, goals. Yesterday there were
two like that. At the end I had to read, I had to open
the reference for them. The problem is we ourselves
do not understand HIV comprehensively. Female,
nurse, rural health centre.
Nurses especially in the hospitals perceived that there
are patients difficult to deal with, for instance skeptical
highly educated patients. Nurses in hospitals also more
frequently perceived offended patients as an issue:
Once we had a patient who was a high school teacher.
We discussed how TB is the leading opportunistic
infection for HIV. At the end it became confusing
because the theory was not clear. At the end she
refused. So how can we deal with patients who are
198
highly educated? Female, nurse, rural health centre.
Even though we have explained this and that...but in
the end it doesn’t seem to suffice. We really are not
effective. Female, nurse, public hospital.
The majority reacts negatively [to the offer]. Patients
feel they have never done any wrongdoings. Patients
feel they could not get it. Especially the VIPs [Very
Important Person – Patients in first class wards]. All the
VIPs refused. Female, nurse, public hospital.
Lack of facilities was an issue perceived by nurses of all
types of structures:
The room is still mixed [with other patients]. So, if
possible, a separate room, which would be better to
give patient education. It’s inconvenient for us to do
it when there are other patients around. Male, nurse,
public hospital We don’t have a special room. Our place
until now is semi-permanent, so mixed Maybe it wasn’t
convenient to offer the test to the patients under such
condition. Female, nurse, rural health centre.
Nurses at all facilities perceived some burden due to
having to offer an HIV test, particularly with limited
time available:
We don’t have enough staff, for our lung clinic. It’s
just me and one assistant. If there are many patients
we really don’t have time, really too overwhelmed
to offer [HIV testing]. We have more time in the
morning. Those patients who accepted the offer
are usually those who come in the morning. Female,
nurse, private hospital.
Nurses in hospitals particularly perceived difficulties
in communication, mainly when it comes to patients
who are ‘hard’ to deal with:
If they have detailed questions we have difficulty
in explaining in details. We can handle general
questions, but university students ask a lot of
questions which are beyond our knowledge.
Female, nurse, private hospital.
Stigmatization of people living with HIV/AIDS
within the community was perceived to be a
barrier, particularly in hospitals:
They had fear, what if they turn out to be [HIV]
positive? What would happen when they have to
face the community. Some of them are community
leaders. Female, nurse, private hospital.
Perceptions of decision makers: specialists and disease control managers
Both specialists and disease control managers
perceived patient-provider communication and
stigmatization as important barriers to VCT uptake:
Yes, I’ve observed that some health workers really
can’t talk, they can’t communicate. Really, it’s not
that they don’t want to do it, but they simply don’t
have the capacity to do it. So we can’t do anything,
because they are all we got. Female, disease control
manager, urban district.
What I liked about the programme [introducing HIV
testing among TB patients] was that the TB patients
got more attention. There was a demand to the
health worker to be able to communicate better.
We basically have nurses and doctors who can
communicate well, but the majority have limited
communication skills and it’s not just a matter of
education, it’s also about personality. Male, disease
control manager, rural district.
Specialists seemed to be more optimistic, giving
more emphasis on the managerial challenges than
on the operational:
The most important thing is that this is integrated
at the top level. If this is still under two different
national programmes then it will be difficult for
policy making. If it’s integrated at the top level, [we]
at the frontline just have to implement. But if at the
top there are still two heads, what can we do? It’s a
sensitive issue, but that’s the reality. Male, senior lung
specialist, public chest clinic and private hospital.
The management system needs to be repaired.
If we’re integrating TB and HIV, the management
becomes more [crucial]. Especially that we’re
involving two different national programmes
together. The financing, the organization... Male,
junior lung specialist, teaching hospital and private
hospital.
They also perceived much less additional burden:
I don’t feel any [significant] additional burden. As
far as I’ve observed, care delivery was not disrupted.
Of course there were some additional things [tasks],
but not so much. Male, senior lung specialist, public
chest clinic and private hospital
However, specialists strongly perceived lack of
knowledgeon HIV to be a major hindrance to
introduce testing, including among colleagues:
Even in this hospital, other specialists don’t
reallyknow [about HIV]. Internal medicine and
dermatovenereology [specialists] know quite a
bit, but others still ask a lot of questions. They only
know it superficially. Male, internist, private and
teaching hospital
But both district control managers and specialists
were not concerned with potential harms to the TB
control programme’s performance:
“No, I am not worried, the patients were not obliged
to be tested ... and I’ve observed no reduction of case
reporting so far. Our patients were not running away”.
Female, disease control manager, urban district
Discussion
Previous studies examining the motivations and
deterrents to HIV testing have been carried out
mainly among groups other than TB patients, i.e.:
pregnant women [14,19]; drug users [12,20]; poor
population [21]; and multiple risk groups [13,22]. Our
study contributes to the evolving body of evidence
on specific factors that influence introduction of HIV
testing among TB patients. This study is limited by
qualitative research boundaries. Issues perceived
by patients and providers were identified. Although
trends emerge, the respective influence of each issue
was not quantified. This could be documented through
a quantitative survey building on our findings, which
points out the key issues to be taken into account.
We have focused on contrasts between patients who
expressed and did not express interest for VCT because
only two patients who expressed interest but did not
attend could be interviewed (group 3) and because
we interviewed more patients who did not express
interest but accepted unlinked anonymous (group 2).
This means our findings can be interpreted in terms of
VCT uptake rather than interest. Although our findings
are context bound, generalization can be considered
to other provinces in Indonesia with similar socioeconomic, HIV-TB epidemiology and health system
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Social & Behavioral
Strikingly, a few nurses’ comments suggested that
some nurses stigmatize people living with HIV:
We’re also worried, what if nurses get it too? It will
[then] become very risky for [HIV-negative] patients.
We need to isolate them if we can identify them, but
until now we don’t know who is positive and who
is not. Even if it’s [just] gonorrhoea and somebody
[staff ] knows, everyone [staffs’ behaviour] becomes
different.Female, nurse, public hospital.
Social & Behavioral
characteristics. Some specific findings may hold in
similar settings in other countries.
Knowledge
Knowledge of TB patients on HIV and its transmission
was strikingly poor with considerable misconceptions,
particularly regarding transmission routes. Pregnant
women in Hong Kong and China reportedly also had
inadequate knowledge regarding HIV transmission
[14,23]. Poor knowledge of HIV among the general
population in the US and pregnant women in
Hong Kong is associated with poor uptake of HIV
testing [14,22]. In addition, our findings suggest
that knowledge of providers regarding HIV and HIVTB is also insufficient. A similar lack of knowledge
particularly regarding HIV testing among physicians
was documented in India [24,25]. The need for
professional education to precede VCT programmes
has also been further affirmed by a study among
health workers in China [23].
Stigmatization
Our data suggests that stigmatization of HIV is
present in the Indonesian society. HIV/AIDS has been
one of the most stigmatized diseases of the last 20
years [26]. HIVassociated stigma has remained a
barrier to testing among pregnant women in China
[23]. Perceived stigmatization among mineworkers
in South Africa and urban inhabitants in Mali
reportedly also deterred them from HIV testing
[27,28]. Stigmatization was also considered to be
an important barrier to HIV testing by nurses in
our study. Our findings further show that there are
even nurses who also stigmatize HIV patients. This
is similar to the findings from China in which 30%
of health workers would not treat HIV patients [23].
However, our data suggests that stigmatization did
not play much role on patients VCT interest. Most
likely this is because HIV/AIDS in our setting is not
yet a widespread disease with high visibility. Other
factors outweigh stigmatization when it comes to
interest in VCT, e.g. a clear indication of the risk for
HIV infection, as effectively communicated by the
care provider, coupled with patients’ concerns for
their personal well-being.
Perceived benefit and risk
Perceived benefit and risk showed considerable
influence on VCT interest among our TB patients.
Mineworkers in South Africa perceive HIV testing to
be more acceptable if antiretroviral therapy (ARVs)
200
become more available [27]. Rates of HIV testing tend
to increase as perceived benefits increase. However,
the most worrying HIV testing barrier is that people
do not perceive themselves at risk [29]. The main
stated reason for refusal of HIV screening among TB
patients in Tamilnadu, India was ‘no risk behaviour’
[30]. Some drug users in the US indeed did not test
for HIV as they had not perceived themselves at
risk [12]. Perception of not being at risk persists as
a barrier to testing in the US, despite self-report of
high-risk behaviors [13]. We likewise encountered a
similar tendency among our TB patients.
Fear of knowing the test result
Our findings indicate that fear of knowing test result
plays a role in VCT interest. Such fear has also been
documented as a barrier among risk populations in
the US [13]. A survey among Indonesian drug users in
Bali province documented that the most important
reason for avoiding HIV testing (55% respondents)
was fear of positive results [20]. A qualitative study
carried out more recently in the same risk population
affirmed the importance of fear of knowing the test
result as a barrier [31].
Perceived burden for utilizing VCT
In addition to transportation, our patients still had to
spend considerable time waiting for the counselor
to see them, undergo the counseling process, have
their blood taken, return home and come back
again the next day for the result. The length of the
process, linked to the perception of not being at risk,
was enough to deter most patients. Our TB patients
were offered transport incentives, but this did not
help much. Other studies have documented similar
observations. Some Indonesian drug users refused
testing because of the long wait and complicated
procedures [20]. Accessibility of the VCT centres
has been shown to motivate TB patients in India to
undergo testing for HIV [30]. Drug users in the US
decided to test because the site was immediately
available and they need not travel far [12].
Communication
A main barrier from the providers’ side was related to
communication. Providers attributed this problem to
difficulties to communicate on HIV issues, lack of time
and adequate facilities. The disease control managers
stated that health workers hardly communicate
with patients and that some health workers did not
have proper communication skills. Patient-provider
Our
findings
additionally
revealed
that
communication was influenced by characteristics
of the patient, provider and healthcare facility
conditions. The worst case scenario occurs when a
skeptical highly educated patient comes into contact
with a nurse worker with poor communication
skills in an overburdened hospital. This highlights
the need for creating the material conditions in
the health services which make it easier for health
workers to interact with patients. Indonesia’s health
services were designed to cope with acute diseases
and the existing service delivery model is clearly not
conducive to effective VCT. HIV/AIDS is a complex
chronic condition requiring long-term involvement,
patient-centered approaches and patientprovider
communication starting from the point of HIV testing
offer.
The magnitude of communication problems
identified in this study was not evenly distributed
across health facility types and was more prominent
in hospitals especially private. These hospitals are
overloaded with patients. They also see more patients
who are challenging to deal with. All of these issues
have to be managed under conditions of limited
time, staff and facilities.
Conclusion
TB patients evidently experienced multiple barriers
that can deter them for HIV testing. The study
highlighted that patients’ and providers’ knowledge
regarding HIV was inadequate in our setting. The
main barriers to HIV testing identified were: fear,
burden to access VCT and communication problems.
Stigma exists in society and caused concerns among
providers, but did not seem to play much role in
patients’ interest in VCT.
If the Ministry of Health intends to move forward with
linked confidential HIV testing among TB patients
through VCT, provider’s and patient’s knowledge
need to be improved simultaneously, the general
healthcare system strengthened by providing the
necessary conditions for effective communication
and patient-provider interaction and offering VCT
at potential DOTS services that can provide results
on the same day. The potential acceptability of the
alternative PITC model would be worth to explore
further. However, it would clearly require even
more demanding pre-conditions and thus should
be reserved for settings with more advanced HIV
epidemic. In any case, efforts to understand and
overcome specific local barriers must accompany
efforts to introduce HIV testing among TB patients.
Competing interests
The authors declare that they have no competing
interests.
Authors’ contributions
YM, RA, PL, MB and PVDS made substantial
contributions to conception and design. YM and
RA collected the data. YM, RA, PL, MB and PVDS
made substantial contribution to analysis and
interpretation of data. YM and PL have been involved
in drafting the manuscript. YM, RA, PL, MB and PVDS
have contributed to revising the manuscript critically
for important intellectual content and have given
final approval of the version to be published.
Acknowledgements
This work was funded by the National Tuberculosis
Control Programme through the TB Coalition of
Technical Assistance (TBCTA) fund administered by the
Netherlands TB foundation (KNCV). Financial support
was also obtained from the Belgium DirectorateGeneral for Development and Cooperation (DGDC)
scholarship. The authors also thank Theodorus
Kusuma, Bahruddin and Tri Agus Nugroho for their
assistance in data collection
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203
B. FOLEY1
E. DONEGAN2
N. SILITONGA3
F.S. WIGNALL3
M.P. BUSCH4,5
E.L. DELWART4,5
1
Theoretical Biology and Biophysics, Los Alamos National Laboratory, Los
Alamos, New Mexico.
2
Department of Anesthesia, University of California at San Francisco, San
Francisco, California.
3
International SOS, PT Freeport, Indonesia.
4
Blood Centers of the Pacific, San Francisco, California.
5
University of California at San Francisco, San Francisco, California.
AIDS Res Hum Retroviruses. 2001 Nov 20;17(17):1655-9
© Mary Ann Liebert, Inc.
205
Sequence Note
Importation of Multiple HIV Type 1 Strains into
West Papua, Indonesia (Irian Jaya)
Abstract
HIV-1 from 16 sexually transmitted disease clinic patients in Timika, West Papua, Indonesia was amplified by RT-PCR and subtyped by a
combination of envelope and gag region heteroduplex mobility analysis (HMA) and direct PCR DNA sequencing. HMA showed the presence
of 14 subtype E (CRF01_AE) and 2 subtype B HIV-1. Phylogenetic analysis of a 540-bp V3–V4 region of gp120 showed that 9 of 10 CRF01_AE
variants clustered tightly with a median distance of 1.3% (range, 0.5 to 2.2%) whereas 1 CRF01_AE variant diverged significantly from the others
(median distance, 10.7%; range, 10.1 to 11.8%). One subtype B virus envelope was typical of United States/European strains whereas the other
appeared to be related to Thai subtype B9 variants. These results reflect the independent introduction of multiple HIV-1 strains into West Papua,
with the rapid spread in the majority of infected patients tested of a single strain of HIV-1E (CRF01_AE).
Introduction
The HIV infection rate for adults in Indonesia, the most
populous country in Southeast Asia (230 million), is
estimated by UNAIDS at a still low 0.05% (http://www.
unaids.org). The World Health Organization estimated that
at the end of 1999 there were 52,000 cases of adult and
children HIV-1 infection in Indonesia. As of March 2001,
the country reported 1299 HIV-1-infected cases, and 479
AIDS cases. The highest number of HIV infections was
reported in Jakarta on the island of Java, the country’s
capital of 10 million people, with 665 HIV/AIDS cases. West
Papua, a province of Indonesia on the island of New Guinea
(also known as Irian Jaya), is the most eastern Indonesian
province with a population of 1.8 million. A total of 384 HIV/
AIDS cases have been reported in West Papua, the highest
frequency of all Indonesian provinces (http://www1.rad.
net.id/aids). We report here on the genetic diversity of
HIV-1 in Timika, a remote city of 50,000 inhabitants located
in the south central lowland of West Papua, 50 km below
the Grasburg mine, the world’s largest gold mine and the
region’s major employer.
In January 1997, a free voluntary sexually transmitted
disease (STD) clinic opened in Timika, and more than
5092 people (73.2% women and 26.8% men) have been
examined. As of January 2000, 7771 sera have been tested
for antibody to HIV with the HIV Determine assay (Abbott,
Abbott Park, IL). HIV-positive serum samples were shipped
on dry ice to San Francisco, California for confirmatory
enzyme immunoassay (EIA; Abbott) and Western blot
(Cambridge Bioscience, Cambridge, UK) testing. Thirtyseven sera were confirmed positive for HIV.
Twenty-four confirmed anti-HIV-1 antibody-positive
serum samples, collected between January 1999 and
February 2000,were available for genetic analysis. Viral
RNA was extracted from 140 μl of serum, using a Qiagen
(Chatsworth, CA) viral RNA extraction kit. Viral RNA was
reverse transcribed with random primers (6 nucleotides
long) and cDNA was used to initiate a nested polymerase
chain reaction (PCR) for the V3–V5 region of the envelope
gene using primers ED5–ED12 followed by primers ES7–
ES8.1
Heteroduplex mobility assay (HMA) was first used to
subtype the envelope V3–V5 regions as previously
described, using the reference strains provided in the
National Institutes of Health (NIH, Bethesda, MD) HMA
env subtyping kit.2 Fourteen individuals carried CRF01_AE
and 2 carried subtype B envelope sequences. Whether
viruses carrying subtype E envelope represent a common
recombinant form (CRF) between subtype A and E (CRF01_
AE) or is a bona fide subtype (HIV-1 subtype A with aberrant
evolution of the env gene) remains a point of debate.3 Here
the HIV Nomenclature Committee designation of such
viruses as CRF01_AE is used.
A 460-bp fragment of the gag region was also amplified
by nested PCR4 and HMA subtyped using gag subtype
reference fragments derived from plasmids provided by
L. Heyndrickx (Institute of Tropical Medicine, Antwerp,
Belgium).4 By using modified electrophoretic conditions to
resolve gag variants belonging to either subtype A, CRF01_
AE, or CRF01_AG we determined that the West Papuan
gag sequences could therefore be amplified from 16 of 24
samples, possibly reflecting variable viral RNA concentration
and/or specimen handling. The demographics of the PCRpositive HIV-1-infected individuals are listed in Table 1.
During HMA, env DNA heteroduplexes formed between
different West Papuan CRF01_AE variants and the same
reference sequences exhibited similar electrophoretic
mobilities, indicating that these variants were closely
related (data not shown). We therefore directly sequenced
all 16 envelope PCR amplicons, using an ABI 3700
automated DNA sequencer (PE Biosystems, Foster City,
CA) with BigDye dNTPs (PE Biosystems) and the m13
forward primer complementary to ES7. Envelope V3–V5
207
Sequence Note
Importation of Multiple HIV Type 1 Strains into
West Papua, Indonesia (Irian Jaya)
sequences could be derived by population sequencing of
PCR products from 12 individuals. Analysis of the HMA of
the four env amplicons that could not be clearly sequenced
showed the presence of multiple slow-migrating DNA
heteroduplexes reflecting the coamplification of diverse
variants.5 Cosequencing of length polymorphic envelope
variants likely accounts for the inability to directly derive
complete V3–V5 sequence data from such amplicons.
HIV-1 env gene sequences were aligned with sequences
representative of subtypes and circulating recombinant
forms (CRFs) of the HIV-1 M group, with multiple samples
from a recent epidemic (the intravenous drug user
epidemic in the Ukraine) included for comparison.6 The
maximum likelihood method implemented in the fast
DNAml program (G. Olsen;http://geta.life.uiuc.edu/~gary/
programs/fastDNAml.html) was used to construct a
phylogenetic tree. Trees constructed with the PHYLIP
Dnadist and Neighbor programs produced trees with
similar topologies.
HIV
subtype
and ID
B, 10
B, 04
E, 28
E, 29
E, 26
E, 20
E, 13
E, 31
E, 24
E, 15
E, 12
E, 08
E, 22
E, 03
E, 23
E, 11
Age
(years)
Sex
Nationality
Occupation
32
24
20
21
22
25
19
19
34
19
19
18
37
21
25
?
Female
Male
Female
Female
Male
Male
Female
Female
Female
Female
Female
Female
Male
Male
Male
Male
Other Indonesian
Papuan
Papuan
Papuan
Papuan
Papuan
Other Indonesian
Other Indonesian
Other Indonesian
Papuan
Papuan
Papuan
Papuan
Papuan
Papuan
Papuan
CSW
Farmer
Housewife
Housewife
Farmer
Unknown
CSW
CSW
CSW
CSW
Housewife
CSW
Miner
Unemployed
Farmer
Farmer
Abbreviation: CSW, commercial sex worker.
Phylogenetic analysis of the 12 sequenced variants
confirmed the HMA-determined subtypes and showed 9
of 10 of the subtype CRF01_AE env sequences to be closely
related, with a median genetic distance of 1.3% (range,
0.5 to 2.2%). A single subtype CRF01_AE variant (IJ13) that
fell outside this cluster was 10.7% (range, 10.1 to 11.8%)
divergent from the other CRF01_AE viruses. Outlier IJ13
alone contained an extra pair of cysteine residues in its V4
region and was therefore typical of CRF01_AE strains seen
primarily in Thailand.7 Phylogenetic analysis showed the
closest relative to all West Papuan CRF01_AE variants to
be CRF01_AE variants from Southeast Asia rather than the
Central African Republic (Fig. 1). One of the two subtype
B variants was typical of United States/European viruses
(IJ04). The other subtype B variant (IJ10) was most closely
related to the subtype B subclade (Thai subtype B’) seen
primarily in Thailand (Fig. 1), although this was not always
seen in neighbor-joining trees, that is, there was less than
50% bootstrap support for IJ10 being within the B’ subclade
of subtype B.
208
Our subtyping results therefore reflect the importation of
at least two different strains of CRF01_AE and two strains
of subtype B HIV-1 into West Papua. The high degree of
sequence similarity among the main genetic cluster of
CRF01_AE variants is reminiscent of the situation during
the early CRF01_AE Thai epidemic in the late 1980s and
early 1990s.1,7,8 The CRF01_AE epidemic in Thailand later
exhibited a gradual increase in its genetic diversity.9
Porter et al. reported subtyping 12 B and 7 CRF01_AE
strains collected from Indonesians in 1993.10 Six of seven
subtype CRF01_AE viruses originated from members of
the Indonesian military stationed in Cambodia. The extra
cysteine pair in the V4 loop of these viruses was detected
only in the West Papuan CRF01_AE outlier IJ13. The closely
related viruses seen in 9 of 10 CRF01_AE cases in West
Papua are therefore unlikely to descend from one of these
earlier Indonesian strains. CRF01_AE viruses have been
reported in southern China, Thailand, Vietnam, Cambodia,
Malaysia, Burma, Laos, South Korea, Taiwan, the Philippines,
and Singapore, with the highest ratio of CRF01_AE to other
subtypes being found on the Cambodian peninsula.11–22
The founder virus for the major cluster detected in West
Papua may therefore have originated from any one of these
neighboring Southeast Asian countries.
The frequent observation of viral founder effects early in
local HIV-1 epidemics indicates that a single introduction
of HIV-1 in a high-risk group can rapidly lead to its
widespread dissemination within that population.1,6,8,23–26
This report provides another example of a strong, although
not absolute, founder effect. The detection of unrelated
variants (a divergent CRF01_AE and two unrelated subtype
B viruses) highlights the importance that increased
sampling of an infected population can have in revealing
the presence of multiple HIV-1 strains and subtypes. The
importation of multiple HIV-1 variants reported here
likely reflects extensive commercial and social exchanges
occurring even in an apparently remote region of the
world.
The majority of HIV transmission in Timika, West Papua,
Indonesia is thought to be heterosexual. Neither sex
between men nor intravenous drug use was recorded in
clinic data collected from participants in this report. The
effect of coexistent malaria infection, which is high in this
area, on the acquisition and transmission of HIV needs
to be determined. Cultural norms for sexual behavior
within Papuan society also need to be explored in order
to understand which educational programs promoting
behavior change are most warranted.
Acknowledgments
We thank Maurits Okoseray, MD and Angelina F. Hambuwan,
MD for their help and support of this project, without which
this work would not have been possible.
1657
HIV-1 IN WEST PAPUA, INDONESIA
Figure 1 Unrooted maximum likelihood phylogenetic tree of Irian Jaya and representative background sequences. Sequences from Irian Jaya
are in boldface italic. Reference sequences are noted by subtype, two-letter country code, and common name, which can be used to retrieve the
sequences from the HIV Sequence Database (http://hiv-web.lanl.gov). The alignment used to build the trees is available by request to btf@t10.
lanl.gov.
209
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This article has been cited by:
Claire E. Ryan , Janet Gare , Suzanne M. Crowe , Kim Wilson , John C. Reeder , Robert B. Oelrichs . 2007. The
Heterosexual HIV Type 1 Epidemic in Papua New Guinea Is Dominated by Subtype CThe Heterosexual HIV
Type 1 Epidemic in Papua New Guinea Is Dominated by Subtype C. AIDS Research and Human Retroviruses
23:7, 941-944.
211
Address reprint requests to:
E.L. Delwart
Blood Centers of the Pacific
UCSF Department of Medicine
270 Masonic Avenue
San Francisco, California 94118
E-mail: [email protected]
Immune Response Towards HIV:
Its Significance in Establishing the Diagnosis
and the Stage of Infection
Yusra1
Siti B. Kresno1
1
Department of Clinical Pathology, Faculty of Medicine of The University of
Indonesia/Dr. Cipto Mangunkusumo General Central National Hospital,
Jakarta, Indonesia.
Acta Med Indones. 2002 Apr-Jun;34(2):76-84
213
Abstract
Human Immunodeficiency Virus (HIV) causes damage to the human immune system and the disease known as Acquired Immune Deficiency
Syndrome (AIDS). This virus is a member of the Lentivirus group of viruses of the Retrovirus subfamily, which has a reverse tran scriptase
enzyme. HIV infects cells which expres CD4, mediated by gp 120. HIV infection changes the lymphocyte migration pattern, the activity of
cytotoxic T cells and CD4 T cell count. The T cell CD4+ count is related to the progressivity of the disease.
Anti gp 120 is the antibody most abundantly produced during HIV infection. Spesific antibody concentration for the antigens vary among
individuals and single individual at different stages of the infection. Expression of the HIV antigen and/or antibody can be used to establishing the diagnosis and determine the stage of the disease. CD4* cells count can be used to determine the stage of HIV infection, to
predict the occurance of opportunistic infection and other complications, and to determine as well as to monitor therapy.
Keywords: HIV, AIDS, CD4*T cells, CD8’T cells, Anti-HIV
Introduction
The Human Immunodeficiency Virus (HIV) is a virus that damages the human immune system, thus
allowing the body to be an easy target of other,
possibly fatal, diseases. The illness caused by the virus
is known as Acquired Immune Deficiency Syndrome
(AIDS). Up to date, the illness is still incurable. The
drugs we have now are only beneficial in reducing
suffering, improving the quality of life, and extending
the survival of AIDS patients.
Since it was first reported in the year 1.981, the
prevalence of this disease has continuously risen.
According to reports from the Ministry of Health of
the Republic of Indonesia, the General Directorate
of Infectious Disease Control and Environmental
Health (DITJEN PPM & PLP) in February 2001, there
were 33 new cases of HIV infection. All patients were
Indonesians, and the majority were males (69.69%).
As many as 72.72% (24 cases) were infected through
intravenous drug use, while the rest were infected
through heterosexual intercourse. There were 18
new AIDS cases in Indonesian citizens reported.
As many of 61.11% were intravenous drug users,
while the remaining number were infected through
heterosexual intercourse. As of February 28th, 2001,
1299 HIV positive cases and 479 AIDS cases have
been reported.1
At Dr. Cipto Mangunkusumo General Central National Hospital, Jakarta, most HIV/AIDS patients were
infected through intravenous drug use among drug
abusers. Most of the patients ranged from 14 years
of age to 20s. A study by Dr. Zubairi Djoerban in
2000 reported 82% of 146 HIV/AIDS cases were drug
abusers infected through intravenous drug use.2
In this review article, we will discuss the structure of
HIV, the way it enters the body, the immune response
towards HIV, and its significant for establishing a
laboratory diagnosis. We hope that this review article
will be useful in increasing our knowledge.
The Structure Of HIV
HIV is an enveloped virus that is relatively easy to
inactivate outside of the body. HIV is a Lentivirus,
a subfamily member of Retrovirus, which tend to
cause chronic infection and a long latency phase. It
possesses the unique enzyme reverse transcriptase,
which can copy viral ribonucleic acid (RNA) into
deoxyribonucleic acid (DNA).3
There are 2 types of HIV, HIV-1- and HIV-2. These
two viruses have very similar structure. HIV-2
has a nucleotide that is more similar to the ape
immunodeficiency virus (75%) compared to the HIV-1
nucleotide. Clinical manifestation and the mode of
transmission of the two viruses are the same, except
that HIV-2 has a milder clinical manifestation, and is
mostly transmitted sexually and perinatally. HIV-2
has a longer seroconversion compared to HIV-1, thus
taking a longer time to advance to the AIDS stage.3
215
Immune Response Towards HIV:
Its Significance in Establishing the Diagnosis
and the Stage of Infection
Based on the “env” and “gag” sequence, HIV-1 is
divided into 9 subtypes, subtypes A to H, and 0. The A
subtype is found in Central Africa and Thailand. Subtype B is found in Europe, North and South America,
Asia, and Australia. Subtype C is found in South and
Central Africa, and Europe. Subtype G is found in
Central Africa, Taiwan, and Russia. Subtype H is found
in Gabon, Zaire, Central Africa. Subtype 0 is found in
West Africa and France.3
The nucleus of HIV-1/HIV-2 takes the form of a cone
consisting of p24 proteins encircling the RNA virus genome, and the reverse transcriptase enzyme.
The HIV genome is divided into 3 regions that code
capsid and matrix protein (gag), reverse transcriptase,
protease and integrase (pol), and envelope protein
(env).3
integrase. Reverse transcriptase is an enzyme that
transcripts viral DNA from its RNA. The integrase
enzyme facilitates the integration of viral DNA into
host DNA. The protease enzyme acts to cut the
viral core protein during viral budding from the
cell. Inhibition of these enzymes can inhibit viral
infectivity.3
The Long terminal repeat OUR) is a gene promotor/
enhancer that interacts with cell proteins to regulate
viral replication.3
The env gene is the gene that codes the formation
of envelope potein gp41 and gpl20. Gp41 is a transmembrane glycoprotein that binds gpl20 to the
virus. While gpl20 is a glycoprotein at the surface of
the virus, which binds with the cel surface receptor
(CD4). These two proteins, especially gp 120, has
great variation. These variation determine the HIV
strain.3
In addition to the gag, pol, and env genes, this virus
has its own regulating gene consisting of the genes
net.’, rev, tat, vif, and vpr. The nef gene plays a role
in determining HIV virulence. Patients infected with
viral strains that underwent deletion of the nef gene,
can life for years without suffering from immune
deficiency. The rev gene is the gene that codes the
rev protein, which changes the replication cycle to
produce all viral particles. The tat gene is the gene
that accelerates viral replication. The vif gene is the
gene that determines viral infectivity outside of the
host cell. The vpr gene facilitates DNA HIV transport
into the cell nucleus and regulates the cell nucleus
and regulates the cycle of the cell itself.3
The gag gene is the gene that codes the synthesis of
core proteins p24 and p 18/p 17.3
HIV’s Mechanism of Entry Into the Host
Cell
The pol gene is the gene that codes the formation
of the enzymes reverse transcriptase, protease, and
HIV, can infect various cells that express CD4. CD4,
as an HIV receptor, is found on 3 types of cells that
function in immune response, the monocyte/
macrophage, including the brain microglia and the
placenta Hofbauer cell, dendritic cells (including
the follicular dendritic cell found in lymph glands
and skin Langerhans cells), and the CD4+ T helperinducer lymphocyte.4,5
The virus enters the cell by adhering to the gp 120 on
CD4. The adherance causes a change in gp120 conformation. Then, viral gp4l fuses with the membrane of
the host cell. 4,5
After penetrating into the cell, the virus removes its
envelope. Using the reverse transcriptase enzyme, it
then transcribes DNA from viral RNA. The viral DNA
then integrates with the host DNA, creating what
is called a provirus. The HIV proviral DNA would
generate more RNAs to be used to make new viral
genomes or act as an RNA messenger to make the
core, envelope, or other additional proteins. The core
216
The Immune System In General
protein and RNA genome are then assembled into a
viral core within the cytoplasm, to be then wrapped in
the envelope protein of the cell membrane, to create
viral particle buds. Finally, the viral particles dettach
from the cell and is ready to infect other cells. 4,5
In addition to requiring CD4 receptors to enter the cell,
HIV also needs co-receptors such as CKR5, CKR2B, CKR3,
and CXCR4. The CKR5 co-receptor is used by the variant
non-syncytium-inducing (NSI) HIV The NSI variant can
live within the macrophage and primary T cell, and is
thus also known as the Macrophage-tropic (M-tropic)
HIV While the CXCR4 coreceptors are needed by the
syncytium-inducing (SI) strains of HIV This latter strain
can only enter T lymphocytes (and lymphoblastoid cell
lines) and is thus also known as the T lymphocyte-tropic
(T-tropic). The CKR2b and CKR3 co-receptors are only
used by a small number of strains.4,5
Mutations in the CKR5 gene (CKR5?32) influence the
interaction between the host and HIV This mutation
is common among people of Western European
descent, with a heterozygote frequency of up to 20%.
Approximately 1 % of the homozygote population
does not express CKR5 in the cell, thus increasing cell
resistance towards HIV infection. Three large studies
on 3000 HIV patients demonstrated that none of these
patients were CKR5?32/ CKR5?32 homozygotes.4,6
A multi-center cohort-analysis in the United States
demonstrated that AIDS does not progress as
rapidly in homosexual non-hemophiliac males with
heterozygote CKR5?32 mutation. A heterozygote
deficiency in CKR5?32 can increase bodily resistance
towards HIV, even though not to the point of
preventing infection, but only enough to slow down
the progressiveness of the disease.4
The immune system is an organization of cells
and molecules that play an important role in the
defense against infection. There are two types
of known immune responses, the innate/natural
immune response, and the acquiredladaptive
immune response. The natural immune response
is mediated by phagocytic cells (neutrophyles,
moncytes and macrophages) and inflammatory
media tors releasing cells (basophiles, mast cells, and
eosinophyles, as well as natural killer (NK) cells. Molecular components that play a role in the natural immune response are complement, acute phase protein,
and cytokines, such as interferon. On the other
hand, the acquired immune response is mediated
by B and T lymphocytes. Antigen-presenting cells
(APC) introduce the antigen to the lymphocytes and
cooperate with these cells in producing an antigen
response. As a response towards antigen, the B cell
secretes specific immunoglobulines that neutralizes
antigens and destroy extracellular microorganism.
T cells assist B cells in producing antibodies and
destroying intracellular pathogens by activating
macrophages and killing infected cells. The natural
and acquired immune responses always cooperate
in combating pathogenous microorganisms.7
The CD4+ T cell is mainly responsible for secretion of
cytokines, which in turn is responsible for increasing
the functions of other cells, such as B lymphocytes,
while CD8+ T cells mainly function as cytotcxic killer
cells. CD4+ T cells can be classified into two types,
type 1 T helpers (Thl) that secrete interleukin-2 and
gamma interferon, and type 2 helper T cells (Th2)
that secrete interleukins 4,5,6, and 10. Cytokines
produced by Th 1 cells facilitate cell-mediated
immunity, including activating macrophages and
T cell-mediated cytotoxicity; while on the other
hand Th2 cells assist B cells in the production of
antibodies.8
Lymphocyte Migration Pattern
All cells involved in the immune system are formed
from pluripotent stem cells in the fetal liver and bone
marrow, which then circulates in the extracellular
fluid. B cells mature within the bone marrow, but T
cells must first enter the thymus to mature completely.
Mature T cells then enter the bloodstream and
remains in the bloodstream for approximately 30
minutes. It then enters secondary lymphoid organs
217
Components of the Immune System
of lymphocytes that
migrate to secondary
lymphoid tiss - and
reduces the number
of
lymphocytes
that return to the
bloodstream.9
such as lymph nodes, the tonsils, and Peyer’s plaque
through high endothelial venules (HEVs). Afterwards,
the lymphocytes then migrate into the parenchyme,
and in this tissue, they encounter spe61 IC antigens.
Lymphocytes that do not encounter their specific
antigen then return to the bloodstream through 1
lymphatic vessels. This lymphocyte migration pattern
is influenced by level of gamma-interferon (IFN) and
al. a-Tumor Necrotizing Factor (TNF-a).7,8,9
In the parenchyme of secondary lymphoid organs,
migrating lymphocytes may encounter interdigitating
dendritic cells (IDCs) and macrophages that can
stimu1. to lymphocytes to proliferate and increase
in number. ithout co-stimulators, the migrating
lymphocytes may dergo apoptosis, thus reducing the
number of lympho cytes. In addition, macrophages
may play a role as HIV r. servoirs.9
Immune Response In HIV Infection
Even though the infectious path of HIV varies from
one person to another, the general pattern of the
development of the disease is already known.
Primary HIV infection is followed by a long latency
phase (of an average of 10 years), which is usually
asymptomatic. This latency phase is then followed
by a symptomatic phase, which could end in death
within 2 years.
Lymphocyte Migration Pattern in HIV Infection
HIV infection causes great changes in the lymphocyte
migration pattern. Acute symptomatic HIV infection is
characterized by unspecific lymphopenia cells only in
CD4+ T cells, but non-selectively causes a reduction in
the number of CD4+, CD8+, and CD20+ subsets within
s: era] days. The event is associated by increased level.
of y-IFN and (x-TNF after infection. These two okines
cause a reduction in the number of lymphocytes
within the bloodstream by increasing the number
218
During this initial
phase, high levels
of free viruses viral
proteins such as p24 can be detected in the blood,
and the level of HIV infection in CD4+ proteins is also
high. Within 2 to 4 weeks, the total number of lymphocytes continues to increase due to the increase
in CD8+ T cells, as a part of immune response against
the virus. However, the CD8+ cells that increase in
number belong to an atypical subset of CD8 that is
not commonly found in lymph nodes, the thymus, or
the spleen, but is commonly found in the lungs. Rapid
proliferation of these cells (over 50 times within 2
days) signifies a stream of cells migrating in the blood
and mucous tissues (such as the lungs and intestines).
After entering the blood circulation, these cells die,
change phenotypes or return to their tissue of origin.9
HIV causes great changes in the composition of
CD4+, CD8+, and B cells in the lymphoid organ.
During the asymptomatic phase, the lymph nodes
change and become follicular and hyperplastic due
to accumulation of follicular dendritic cells (FDC)
that bind viral particles in germinal centers. This
event occurs continuously in germinal centers and
paracortex. The number of CD4+ cells and CD4/CD8
ratio in lymph nodes remain stabile, even though the
number of CD4+ cells in the bloodstream is reduced.
The CD8+ phenotype that is initially dominated by
CD45RA hi then changes into CD45RA lo.9
CD4-gp120 adhesion create clusters of CD4 cells
around FDCs.,Gpl20 that are fused with IDCs, macrophages, or other CD4 cells group around FDCs in
the germinal center and paracortex, thus reducing
the number of lymphocytes that return to the
bloodstream.9
The Role of Cytotoxic T Cells In HIV Infection
During viral infections in general, the cytotoxic Tcells
are a population of cells that play an important role in
controlling acute infection by recognizing and destroy-
ing cells infected by the virus (even though this often
increases damage of the host), thus preventing viruses
from replicating and producing new virions.9
Cells infected by a virus signals itself as a target for
cytotoxic T cells by showing a peptide from the viral
protein bound to class : MHCs at the surface of the cell.
Cytotoxic T cells recognize and bind with these MHCpeptide complex and then kill the cell by 2 means. The
first way is by creating a perforation that destroys the
membrane of the target cell, creating a hole to insert
granzyme from cytotoxic T cells into the target cell. This
enzyme activates the caspase enzyme, which mediates
apoptosis of the target cell. The second method is where
cytotoxic Tells bind to-Fas-molecules on-the-target cell
using its Fas ligands, so that it is activated and undergoes apoptosis. The two ways prevent the virus from
using its host to replicate and protect itself. The virus
that is released is quickly neutralized by the antibody.8
CD8+ T cells can also directly kill infected cells by
producing a number of cytokines, including alpha
TNFs and lsymphotoxins. Gamma IFNs that are also
produced by CD8+ T cells, together with alpha IFNs
and 0 IFNs secreted by the infected cell, could also
increase the defense of the cells around the viral
infection.8
HIV infected ThO/Th2 CD4+ cells express CD30. This
increases the expression of CD30 Ligards (CD30L) on CD8+
T cells. The interaction between CD30 and CD30L increases
viral replication, death of CD4+ T cells, and increases the
release of soluble CD30s (sCD30). The level of serum
sCD30 during the initial phase of HIV infection accelerates
the progress of the disease into AIDS. After the number of
CD4+ T cells is reduced during the advance stage of HIV
infection, CD8+ T cells expressing CD30L increases the
apoptosis of CD8+CD30+ T cells. This may be the cause in
the reduction of CD8+ T cells in symptomatic AIDS.10
How HIV Reduces the Number of CD4+T Cells
The number of viruses demonstrates a correlation
with a reduction in the number of CD4+ T cells and
219
Several authors
found an increase
in the activity of
specific cytotoxic
T cells for HIV
protein in patients
before and during
seroconversion.
Koup
et
al
demonstrated
that there is
a
correlation
between a great
number of HIV
specific cytotoxic
T cells precursors
with the rate in
reduction -of free
-detectable HIV.
The
presence
of cytotoxic T
cells
precedes
neutralizing
antibodies, sometimes up to several months. The study demonstrated
that a reduction in free viruses and intracellular viruses
are caused by lysis of the. cell infected by HIV by CD8+
cytotoxic T cells. This also demonstrates that CD8+ cells
activated from HIV infected individuals produce a number of soluble cytokines (including CAF/CD8+ T cell
produced antiviral factors), a cytokine that can directly
inhibit HIV replication in CD4+ T cells, without causing
lysis. Such response also occurs during acute infection
prior to seroconversion, and, may play a role in controlling virus production.8
the progress of the disease. Intense virus replication
greatly influences the turnover rate of CD4-T cells.
From the studies by Ho et al” and Wei et al’0, we know
that HIV replicates at a rate of 1010 per day, while its
half-life is 6 hours.11,12
During asymptomatic HIV there is a slow and relatively constant reduction. in CD4+ cells. From various
studies, we found that this reduction in CD4+ T cells
may be caused by various mechanisms.13
The reduction in the number of CD4+ T cells may
be due to cell damage due to virus infection.
Viruses replicating within the cells destroys the cell
membrane during viral budding. In addition, the cell
also no longer functions, due to viral RNA, DNA, and
proteins.4
HIV infected CD4+ cells present viral antigen (gp 120).
These cells become a target for immune responses
through the antibody-mediated and cell-mediated
immune response. This kills the CD4+ cell and thus
reduces its number.4
HIV can infect CD34+ stem cells as a substitute
for T cell precursors. Destruction of the stem cell
causes failure to produce new T cells to replace T
cells that are destroyed/killed due to HIV infection.
Additionally, destruction of thymus epithelial cells
may also disturb T cell maturation. Destroyed lymph
nodes also inhibit the T cells after normal contact with
the antigen, thus reducing/eliminating the ability for
clonal distribution and T cell pool replacement (T cell
anergy).4,14
HIV infected CD4+ T cells that lost its ability to produce
cytokines, which is important in assisting its function.
The first loss of function in CD4+ cells is its ability to
bind with antigens that it had encountered. This is
then followed by a loss of allogenic response, and
finally, the loss of non-specific mytogenic response,
such as phytohaemagglutinin.4
The number of CD4+ cells that rapidly decline initiates AIDS in most patients, often preceded by a
level of CD4+ cells of over 300/ul. In a Dutch study,
they found that 18 months prior to AIDS, there is a
reduction of CD4+ cells up to 3-5 times the previous
year. Subsequent studies correlated the change
with changes towards a more virulent (syncytiuminducing) type of virus. The loss of lymphadenopathy
220
indicates a bad prognosis. Loss of the immune
system to combat viruses in the lymph glands causes
rapid virus turnover, mutation towards more virulent
types, and rapid reduction in CD4+ cells.4.14
CD8+ cells are also influenced b the reduction in the
number and function of CD4+ cells. Even though
CD8+ cells remain in adequate numbers, they still
have difficulty facing HIVs due to reduced assistance
due to the lack of production of various cytokines by
CD4+ cells, such as IL-2.4.14
Even though only CD4+ T cells can be infected by HIV,
when the number of CD4 cells falls below 200/ul, the
CD8+ T cells (monocytes and dendritic cells) may also
be infected. The mechanism of infection is still unclear.
CD8.+ cells may be infected in the thymus when they
still have CD4 and CD8 antigens on their surface. HIV
specific CD8+ cells may be infected during the process
of destroying HIV infected CD4+ cells, or CD8+ cells
may present another (still unknown) receptor for HIV
Whatever the mechanism, the possibility that HIV
infected CD8+ cells play a role in increasing viral load
and reducing the immune function during the final
stage of infection needs further research.
Antibody Response in HIV Infection
As towards other infectious agents, the human body
responds to HIV infection by producing antibodies.These
antibodies are usually produced within 6 to 12 weeks
after infection and throughout the infection. The period
after infection before the appearance of antibodies is
called the window period. Produced antibody function
to eliminate viruses by binding directly with the virus or
to the expression on virus-infected cells.15,6
Viral structural proteins (gag, env, pol) are strongly
immunogenic. Antibodies against the gag protein
(p24, p55) usually appear during the beginning of
Even though virus regulation proteins (nef, vif,
tat, and rev) are antigenic in nature, the level of
antigenicity varies according to the characteristic of
the antigen and the level of antigen expression. The
antibody against HIV- I regulated proteins cannot
be persistently or transiently detected in 20-70% of
infected individuals. There is no correlation between
antibody response towards regulatory proteins and
the progress of the disease.15
Antibodies against gp12O are most frequently produced. Several individuals have a stronger response
against p24. However, most individuals respond to all
virus components during the course of infection. The
concentration of antibodies specific to all antigens
also varies among individuals, and varies within an
individual at different points of infection.
The antibody response shown in the figure above is
immunoglobulin G (IgG) antibody. IgM response is
inconsistent in HIV infection. A study demonstrated
that the IgM response can be detected in 49% of
patient serum 2 weeks prior to IgG response, and
remains for approximately 3 months. However, since
its appearance is inconsistent, IgM evaluation has not
been widely used. In addition, more sensitive IgM
testing needs to be developed.15,16
Detection of HIV specific IgM may be useful in detecting
HIV in neonates, since maternal IgM does not pass
through the placental blood barrier. However, presently available IgM evaluation does not demonstrate
consistent results, and is thus not routinely used. In
many individuals with seroconversion and in neonates,
no IgM antibody was found. Thus, the absence in
specific IgM antibody cannot be considered to be
an absence of infection. This may be due to a low
sensitivity and specificity of the test for IgM detection.
It is unclear when IgM antibodies are produced in the
neonate, but it is estimated to be produced at an age
of approximately 6 months. A positive 1gM should be
viewed with conscious, since p„rturbing substances
such as the rheumatoid factor may create a false
positive. RF is an IgM antibody that reacts with IgG. If
IgM is found in infant serum, it would react with antiHIV specific IgG class from the mother, thus causing a
reaction in the test. This is also disturbing, since if an
anti-IgM conjugate is used, it also produces a reactive
result.”
Such antibody reactivity pattern may also be found
in normal individuals who have not been infected by
HIV. How this occurs is still unclear. It may be due to
an unknown cross reaction against retrovirus or as
a result of another illness, such as an autoimmune
disease. 15,16
The Significance in the Mechanism.of Infection and
the Pattern in HIV Antigen Expression Pattern in Establishing Laboratory Diagnosis of HIV Infection
Through the production of cytokines that regulate
the activity of B lymphocytes, macrophages, and
CD8+ T cells, CD4+ T helper cells play the chief role in
most immune responses. In reality, CD4+ T cells are
selectively infected by HIV cells, then the analysis of
CD4+ T cell response towards HIV infection becomes
very complex.16
CD4+ T cell count is utilized to determine the stage of
HIV disease and predict the presence of opportunistic infection and other complications. When initiating
antiviral treatment, evaluation of CD4+ T cell count
and viral load is used as initial findings to monitor
treatment.17
There is a correlation between clinical symptoms and
the immunopathogenesis of the reduction in CD4+
cells. During the primary phase of infection there is an
initial reduction, followed by an increase, in the number
of CD4 cells. During this phase, symptoms such as fever,
myalgia, arthralgia, adenopathy, malaise, rash, and
menigoencephalitis may be found. Anti-HIV antibodies
have not been form, and thus only the p24 antigen
can be detected. During the initial asymptomatic
phase, there is an-immune reduction (CD4 cell count
> 500/ul), but the immune system is still able to
control infection and malignancy. The strength of the
immune stimulation can develop into autoimmune
diseases, and lymph cells often develop into persistent
generalized lymphadenopathy. Lymphadenopathy
is one of the first detected symptoms as a clinical
fording of HIV infection. During this phase, anti-HIVs are
formed, and p24 antigens disappear. An intermediate
immune reduction (CD4 cell count 200-500/ul) causes
small infections in the skin and mucous tissues. Oral
candidiasis, as well as sarcoma caposi, occur at a CD4
221
infection. As the disease progresses, the antibody
against p24 is usually reduced, followed by an
increased in p24 antigens. Antibody against env
proteins (gpl20, gp4l) and pol appears simultaneously
or a little afterwards. Antibody against env remains
throughout the course of the infection.11,16
cell count of approximately 250/ul. At this stage, the
immune system has great difficulty in conducting its
function. Generalized persistent lymphadenopathy
can disappear due to destroyed lymph nodes, which is
the beginning of the AIDS phase. Anti-p24 antibodies
are reduced, accompanied by an increase in p24
antigens. Severe immune deficiency (CD4 cell < 200/
ul) indicates the collapse of the immune system,
increasing opportunistic infection and malignancy.
During this phase, there is an increase in p24 antigen,
accompanied by loss c f anti-p24 antibodies.4
Evaluation of the absolute CD4 count is greater
compared to the percentage CD4 (the percentage of
lymphocytes that express CD4) or CD4:CD8 ratio. This
increase in the physiology of CD8 population due to HIV
i:ifection may obscure the results of CD4:CD8 ratio.17
Diurnal variation may also influence the evaluation
in CD4 count up to 50%. Thus, the evaluation
should be conducted at the same time of day, and
evaluation during the acute phase of the disease
(such as influenza, urinary tract infection) should be
avoided and cannot be used for the diagnosis of HIV
infection. During the first weeks after the diagnosis,
3 values are needed for the base point value. After
that, evaluation is performed every ( months in
asymptomatic patients or every 3 months after the
appearance of symptoms.17
Antigen expression or anti-HIV antibodies may
be used to determine the diagnosis and stage of
disease. The presence of p24 antigen signifies initial
infection and advance stage of HIV infection. During
the window period, when anti-HIV antibodies are still
undetected, a method of evaluation is needed to be
able detect p24 antigens for the diagnosis of HIV.18,19
After 6-12 weeks of infection, anti-HIV antibodies are
produced. During this phase, detection of anti-HIV
antibodies can be used to diagnose HIV However, p 24
could suddenly disappear. A reduction in serum antip24 titer is a bad prognosis for HIV-infected patients,
since it demonstrates a high viral replication.16
HIV-infected patients with negative HIV antibodies
can pass the initial HIV screening test. This can occur
curing the window period phase. They have now
develincoped test to simultaneously detect p24 Ag
and anti-HIV to increase the sensivity during the
window period. 18,19
222
A study by Binsbergenl8 and Weberl9 proved that
HIV evaluation that is able to detect p24 and antiHIV is; able to detect 65% seroconversion during the
window period. Using the p24 antigen HIV evaluation,
100% seroconversion during the window period can
be detected. However, anti-HIV evaluation is unable
to detect seroconversion during the window period.
Summary
HIV is a retrovirus that causes chronic infection with
a long latency phase. This virus has an envelope and
reverse transcriptase enzyme. HIV can infect cells
that express CD4 and enter the cell through gp I20
adhesion to CD4. In addition to requiring CD4, HIV
also requires co-receptor to enter the cell.
In HIV infection, the immune system undergoes
changes in lymphocyte migration pattern, the
number of CD8+ and CD4+ T cells, as well as the
formation of anti-HIV antibodies.
CD4+ T cell count can be used to determine the
stage of HIV, to predict opportunistic infection and
other complications, as well as evaluate and monitor
treatment. Expression of antigens/antibodies against
HIV can be used to determined the diagnosis and
stage of disease.
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Toxoplasma Encephalitis in HIV-Infected Person
Evy Yunihastuti1
Darma lmran2
Nanang Sukmana1
1
Division of Allergy and Clinical Immunology, Department of Internal Medicine,
Faculty of Medicine University of Indonesia, Ciptomangunkusumo General
Hospital, Jakarta.
2
Department of Neurology Faculty of Medicine University of Indonesia, Cipto
Mangunkusumo General Hospital, Jakarta.
Acta Med Indones. 2005 Jan-Mar;37(1):49-50
225
Toxoplasma Encephalitis in HIV-Infected Person
A 26-years old male PLWHA (people living with HIV/
AIDS) was admitted in Pokdisus clinic with fever
with severe progressive headache for two weeks.
He also complained nausea and vomitus. Physical
examination showed left hemiparesis and left ptosis.
His CD4 level was 14 cell/mL and his viral load was
1.592.572 copy RNA/mL.
Brain MRI with contrast showed multiple hipointense
lesions with ring enhancement and perifocal edema
in brain stem, right ganglia basal, and right frontal
lobe (figure l a and l b). Toxoplasma IgM was negative
and toxoplasma IgG was more than 300 IU/mL. The
diagnosis was encephalitis toxoplasma, HIV infection,
and hepatitis C infection. He received pirimethamine
25 mg bid, clindamycin 600 mg every 6 hours for
6 weeks, and leucovorin 15 mg qd, followed by
maintenance dose with pirimethamine 25 mg qd
and ciindamycin 300 mg every 6 hours. His condition
was improved on the 4th days of antitoxoplasmic
treatment. After completion of acute phase therapy,
he was able to do normal daily activities. He was also
treated with highly active antiretroviral agent (HAART)
regimen consisted of zidovudine (AZT), lamivudin:.
(3TC) and nevirapine (NVP) for 2 weeks. NVP was
changed to efavirenz (EFV) due to hepatotoxicity
(elevated liver transaminase 5 times normal limit).
He stopped using all the drugs after 6 weeks starting
maintenance therapy due to economic problem.
Five weeks after stopping using the drugs, he started
complaining severe occipital headache with unstable
gait. Brain CT scan with contrast showed multiple
hipodense ones in bilateral ganglia basal with
contrast enhancement and perifocal cerebral edema.
We assumed that those were new lesions, different
from the previous lesions. Acute phase therapy with
the same regimen was restarting in this patient.
227
Progressive neurological deficit in PLWHA with Cb4
< 100 cell/mL with compatible imaging of focal
brain lesion is highly suggestive of encephalitis
toxoplasma. Encephalitis toxoplasma is the most
common etiology of focal brain lesion in HIV infected
persons. Presumptive therapy should be started in
this condition for 2 weeks. If there were no clinical
improvement, we would have to explore another
cause, such as tuberculoma, CNS lymphoma, and brain
abscess. Antitoxoplasmic drugs are active against
trophozoit form of Toxoplasma gondii, but they have
no effect on cyst form of the parasite. To avoid relapse,
228
continuation of therapy after the acute phase using the
same regimen at the lower dosages is recommended
for as long as the immunosupression persists. The
recommendation is to discontinue maintenance
therapy when CD4 > 200 cell) L for at least 6 months,
without any symptoms. Clinical experience showed
that treatment could not be discontinued even after
complete resolution of clinical and radiological sign
of acute toxoplasma encephalitis, because relapse
occurred in approximately one third of the cases in
which treatment was halted.
I Gede Putu Surya1
Karkata Kornia1
Tjok Gde Agung Suwardewa1
Mulyanto2
Fumio Tsuda3
Shunji Mishiro3
1
Department of Obstetrics and Gynecology, Udayana University, Bali,
Indonesia.
2
Department of Immunology, Mataram University, Lombok, Indonesia.
3
Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan.
J Med Virol. 2005 Apr;75(4): 499–503
New York NY WILEY-LISS
229
Serological Markers of Hepatitis B, C, and E Viruses
and Human Immunodeficiency Virus Type-1
Infections in Pregnant Women in Bali, Indonesia
Abstract
Except for hepatitis B virus (HBV), there havebeen few data on serological markers of hepatitis viruses such as hepatitis C virus (HCV) and E virus
(HEV), and human immunodeficiency virus type-1 (HIV) in Bali, Indonesia. During 5 months from April to August 2003, sera were collected
from 2,450 pregnant women at eight jurisdictions in Bali, and they were tested for markers of these viruses. Only one (0.04%) was positive
for antibody to HCV, but none for antibody to HIV. Hepatitis B surface antigen (HBsAg) was detected in 46 (1.9%) at a prevalence significantly
lower than that in 271 of the 10,526 (2.6%) pregnant women in Bali surveyed 10 years previously (P<0.045). The prevalence of hepatitis B e
antigen in pregnant women with HBsAg decreased, also, from 50% to 28% during the 10 years (P<0.011). Antibody to HEV (anti-HEV) was
examined in 819 pregnant women who had been randomly selected from the 2,450. The overall prevalence of anti-HEV was 18%, and there
were substantial regional differences spanning from 5% at Tabanan district to 32% at Gianyar district. Furthermore, the prevalence of anti-HEV
differed
substantially by their religions. In the Sanglah area of Denpasar City, for instance, anti-HEV was detected in 20 of the 102 (20%) Hindus,
Abstract
significantly more frequently than in only 2 of the 101 (2.0%) Muslims (P<0.001). Swine that are prohibited to Muslims, therefore, is likely
to serve as a reservoir of HEV in Bali. In conclusion, HBV is decreasing, HCV and HIV have not prevailed, as yet, while HEV is endemic probably
through zoonotic infection in Bali. J. Med. Virol. 75:499–503, 2005. 2005 Wiley-Liss, Inc. KEY WORDS: Bali; hepatitis B e antigen; hepatitis B virus;
hepatitis C virus; hepatitis E virus; human immunodeficiency virus type-1; pregnancy; zoonosis
Introduction
Bali is an island in Southeast Asia, between the Bali sea
and the Indian Ocean, and has approximately 3 million
inhabitants. The prevalence of infection with hepatitis
C virus (HCV) has not been examined, as yet, although
there are a few reports on serological markers of
hepatitisBvirus (HBV) and hepatitisEvirus (HEV) in
Bali [Brown et al., 1985; Wibawa et al., 2004]. Nor is it
known whether the population in Bali is affected by
human immunodeficiency virus type-1 (HIV), except
in commercial sex workers [Ford et al., 2000].
Since 1993, pregnant women in Bali have been tested
for hepatitis B surface antigen (HBsAg) in serum, and
those positive for HBsAg were examined further for
hepatitis B e antigen (HBeAg). Babies born to pregnant
women carrying HBsAg along with HBeAg have
received the passive and active immunoprophylaxis
with hepatitis B immune globulin and vaccine [Tada
et al., 1982]; it is found highly efficacious in preventing
the persistent HBV carrier state in high-risk babies in
Japan [Noto et al., 2003].
Taking advantage of routine screening for HBsAg
of pregnant women in Bali, sera were tested for
serological markers of HBV, HCV, HEV, and HIV. The
results highlighted decreasing HBV infection, rare
infection with HCV and HIV, and a high exposure
to HEV that depends on habits and religions of the
Balinese.
Pregnant Women in Bali
During 5 months from April to August 2003, sera
were obtained from 2,450 pregnant women,at major
hospitals in the eight jurisdictions of Bali (Fig. 1), on
routine surveys for HBsAg for preventing the perinatal
transmission of HBV. Their mean age was 275 (SD)
years (range: 16–45 years). The sera were tested for
HBsAg, antibody toHCV(anti-HCV) and antibody
toHEV(anti-HEV), as well as antibody toHIV(anti-HIV).
HBeAgwas examined only in sera positive for HBsAg.
Sera from all pregnant women were tested for
serological markers of these viruses, except for antiHEV which was examined in approximately 100 each
randomly selected in the eight jurisdictions. AntiHEV was tested in an additional 90 sera from Muslim
pregnant women living in the Sanglah area of
Denpasar City, in an attempt to find any differences
in the prevalence between Hindus and Muslims. The
design of the serological survey was in accord with
the 1975 Declaration of Helsinki, and approved by
Ethics Committee of institutions. Every pregnant
woman gave an informed consent.
231
Serological Markers of Hepatitis B, C, and E Viruses
and Human Immunodeficiency Virus Type-1
Infections in Pregnant Women in Bali, Indonesia
Serological Tests for Markers of HBV, HCV, HEV, and
HIV
HBsAg was tested by hemmaglutination and
immunochromatography (Entebe HBsAg RPHA and
Entebe HBsAg Strip, respectively: Hepatika Laboratory,
Mataram, Indonesia) and HBeAg by enzyme-linked
immunosorbent assay (ELISA) (HBeAgELISA: Institute
of Immunology, Tokyo, Japan). Anti-HCV was
determined by the dipstick method (Entebe AntiHCV Dipstick: Hepatika Laboratory). Anti-HEV of
IgG class was determined by ELISA with use of a
recombinant HEV capsid protein of genotype IV by
the method of Mizuo et al. [2002], and anti-HIV by
immunochromatography (Entebe Anti-HIV Strip:
Hepatika Laboratory).
The prevalence ofHBsAgin Negara in the west (Fig. 1)
was by far the highest at 4.5% (6/132), in remarkable
contrast to 0.6% (1/161) in Tabanan and 0.8% (1/133)
in Singaraja. Differences fell short of being significant,
however, due to low numbers of pregnant women
examined.
Figure 2 illustrates age-specific frequencies of HBsAg
and HBeAg. The prevalence of HBsAg stayed
constant in a range from 1.6% to 2.5%, while HBeAg
decreased with age; it was most frequent in pregnant
women aged younger than 25 years (53% [8/15]).
Of 46 pregnant womenwho carried HBsAg, the 13
withHBeAgin serum were significantly younger than
the 33 without HBeAg (244 vs. 296 years, P<0.0190).
Anti-HCV and Anti-HIV in Pregnant Women in Bali
Infection with HCV or HIV was very infrequent in
pregnant women in Bali. Anti-HCV was detected in a
single pregnant woman in Denpasar, while anti-HIV
was not in any. Thus, the prevalence of anti-HCV was
0.04% and that of anti-HIV less than 0.04%.
Anti-HEV in Pregnant Women in Bali
Fig. 1. Map of Bali with eight districts where markers of hepatitis
viruses and HIV among pregnant women were surveyed.
HEV RNA was determined by the polymerase chain
reaction with primers deduced from the nucleotide
sequences in the open reading frame 2 that are
preserved irrespective of genotypes [Mizuo et al.,
2002].
Statistical Analyses
Categorical variables were compared between groups
by the Chi-square test, and continuous variables by
the Welch’s t-test. Differences with a P value <0.05
were considered significant.
Results
HBsAg in Pregnant Women in Bali
Frequencies of HBsAg, anti-HCV, anti-HEV, and
anti-HIV in the eight jurisdictions in Bali are listed
in Table I. Overall, HBsAg was detected in 46 of the
2,450 (1.9%) pregnant women during 5 months from
April to August 2003. This prevalence of HBsAg was
significantly lower than that in 271 of the 10,526
pregnant womenin Bali surveyed 10 years before in
1993 (1.9% vs. 2.6%, P<0.045).
232
Anti-HEV was examined in all the 41 pregnant women
from Karangasem, and 86–196 randomly selected
among those from the other districts. Anti-HEV was
detected in 151 of these 819 (18%) pregnant women,
producing an overall prevalence of 18%. The mean
absorbancy in ELISA on the 151 sera positive for antiHEV was low at 0.790.61. HEV RNA was not detected
in any of the 20 sera with a high absorbancy (>1.50).
There were marked regional differences in the
prevalence of anti-HEV. It was low in Tabanan (4.7%
[4/86]) and high in Gianyar (32% [32/101]) and Bangli
(27% [25/93]); the difference between Tabanan
and Gianyar was statistically significant (P<0.0001).
Frequencies of anti-HEV in the other five districts
were much the same and ranged from 11% to 19%.
There were no differences in the mean age among
pregnant women from distinct religions.
The prevalence of anti-HEV differed with regard to
the religion of the pregnant women (Table II). Overall,
anti-HEV was detected in 149 of the 769 (19%)
Hindus, at a frequency significantly higher (P<0.012)
than that in two of the 50 (4.0%) non-Hindus (mostly
Muslims).
TABLE I. Serological Markers for HBV, HCV, HEV, and HIV Infections in the Eight
Jurisdictions of Bali
Jurisdictions
Bangli
Denpasar
Gianyar
Karangasem
Klungkung
Negara
Singaraja
Tabanan
Total
HBsAg
2/115 (1.7%)
29/1,594 (1.8%)
3/151 (2.0%)
1/41 (2.4%)
3/123 (2.4%)
6/132 (4.5%)
1/133 (0.8%)
1/161 (0.6%)
46/2,450 (1.9%)
Anti-HCV
Anti-HEV
0/115
1/1,594 (0.06%)
0/151
0/41
0/123
0/133
0/132
0/161
1/2,450 (0.04%)
25/93 (27%)
35/196 (18%)
32/101 (32%)
6/41 (15%)
19/98 (19%)
11/100 (11%)
19/104 (18%)
4/86 (4.7%)
151/819 (18%)a
Anti-HIV
0/115
0/1,594
0/151
0/41
0/123
0/133
0/132
0/161
0/2,450 (<0.04%)
a
Anti-HEV was examined in only 819 samples, randomly extracted from among inhabitants from each
jurisdiction, except for Karangasem all pregnant women from where were examined.
The frequency of anti-HEV higher in Hindus than
non-Hindus held in pregnant women from all the
eight jurisdictions. In Denpasar where more women
were examined than the other seven districts, antiHEV occurred more often in Hindus than non-Hindus
(19% [33/175] vs. 9.5% [2/21]); the difference fell short
of being significant due to small numbers examined.
Fig. 2. Age-speciﬁc prevalence rates of HBsAg and HBeAg in
2,450 pregnant women in Bali.
For evaluating the influence of religions on HEV
infection, pregnant women living in the Sanglah area
of Denpasar City were examined for the prevalence
of anti-HEV; inhabitants in this narrow area were
surveyed in an attempt to exclude environmental
factors such as water quality and sanitation. AntiHEV was significantly more frequent in Hindus
than Muslims there (20% [20/102] vs. 2.0% [2/101],
P<0.001).
Discussion
In surveys for serological markers of HBV and HCV
infections among blood donors performed in 1991
in Jakarta, Indonesia, HBsAg was detected in 5.8%
and anti-HCV in 17.7% [Sastrosoewignjo et al.,
1991]. HBV andHCVstrains indigenous to Indonesia
are reported in blood donors and hepatitis patients
there [Sastrosoewignjo et al., 1991; Hadiwandowo
et al., 1994; Mulyanto et al., 1997]. Data are still
inadequate, however, on serological markers of HBV
and HCV infections, as well as HIV infection, in the
general population in Bali that is isolated from the
other Indonesian archipelagos by the sea. Nor are
there any data available for the exposure to HEV in
Bali, except for a recent report by Wibawa et al. [2004]
on 276 family members of chronic liver disease and
797 voluntary blood donors.
Taking advantage of the routine screening for
HBsAg, 2,450 pregnant women in Bali were tested for
serological markers of HBV, HCV, and HEV infections,
and HIV infection. The prevalence of HBsAg examined
during 5 months in 2003 was significantly lower than
that in 1993 (1.9% vs. 2.6%, P<0.045). It is not certain,
however, how the prevalence of HBV markers surveyed
in pregnant women who give birth to their babies in
hospitals is extended to the general population in
Bali, where the majority of deliveries are conducted
by midwives at home. Wibawa et al. [2004] detected
HBsAg in 38 of the 797 (5%) voluntary
233
Hepatitis Virus Infections in Pregnant Women in Bali
TABLE II. Frequencies of Anti-HEV in Hindu and
Non-Hindu Women in Various Districts of Bali
Districts
Hindu
Bangli
25/92 (27%)
Denpasar
33/175 (19%)
Gianyar
32/100 (32%)
Karangasem
6/39 (15%)
Klungkung
19/91 (21%)
Negara
11/90 (12%)
Singaraja
19/99 (19%)
Tabanan
4/83 (4.8%)
Total
149/769 (19%)
a
Non-Hindu
Differences
0/1
2/21 (9.5%)
0/1
0/2
0/7
0/10
0/5
0/3
2/50 (4.0%)
NSa
NS
NS
NS
NS
NS
NS
NS
P < 0.012
Not signiﬁcant.
blood donors and 18 of the 276 (7%) family members
of patients with chronic liver disease from Bali. Their
results stand at a substantial variance with ours.
Anti-HCV in pregnant women in Bali was low at 0.04%,
in contrast to the detection of anti-HCV in 17.7% of
voluntary blood donors in Jakarta [Sastrosoewignjo
et al., 1991]. Although data are lacking for the
prevalence of anti-HCV in the Balinese, it is reasonably
expected to be low in the general population of Bali;
Wibawa et al. [2004] detected anti-HCV in 6 of
the 796 (0.8%) blood donors. With rapid increases
of immigrant and tourists into Bali, however, the
exposure to HCV may expand in the foreseeable
future. In support of this view, the prevalence of antiHIV among female sex workers in Bali is reported to
be higher for immigrants than the Balinese [Ford et
al., 2000].
To address possible concerns on the sensitivity of
locally produced assays for HBsAg and anti-HCV, the
Entebe kits for these viral markers have been used
during the past 18 and 8 years since 1986 and 1996
for HBsAg and anti-HCV, respectively, for screening
blood units at many blood centers in Lombok and
other islands of Indonesia. Indisputable decrease (to
practically zero) in the incidence of posttransfusion
hepatitis B and C since then would indicate a high
sensitivity of these tests.
HIV infection has become very rare in female sex
workers in Bali (0.2%), although the frequencies of
sexually transmitted disease such as gonorrhoea
(60.5%), chlamydia (41.3%), and human papilloma
virus (37.7%) remain very high [Ford et al., 2000].
The reasons for such a low exposure to HIV in the
Balinese, even in highrisk groups, are not clear. It is
a surprise, especially because a pandemic of HIV is
expected in Indonesia [Anonymous, 1996]. Isolation
from the other areas of Indonesia, surrounded by sea,
may have prevented exposure to HIV and HCVthat
234
have been introduced more recently than HBV. In
addition, heavy punishments imposed on the use of
illegal drugs may have prevented the spread of these
blood-borne viruses there.
Overall, anti-HEV was detected in 18% of pregnant
women living in eight jurisdiction, at a frequency
comparable to 18%–20% recently reported in Bali
[Wibawa et al., 2004]. Previous findings point to the
zoonotic foodborne transmission that may play an
important role in HEV infection among Japanese
people. For instance, some individuals who ate
sashimi prepared from deer caught in the wild [Tei
et al., 2003] or feral boar’s liver in the raw [Matsuda
et al., 2003] developed acute or fulminant hepatitis
E. In addition, Yazaki et al. [2003] have suggested
the ingestion of pig’s liver as a major risk factor for
hepatitis E among residents of Hokkaido, Japan.
These observations in Japan instigated us to look
into whether zoonotic food-borne transmission of
HEV also occurs in inhabitants of Bali where anti-HEV
has not been surveyed extensively. As the results, the
prevalence of anti-HEV was found to be more frequent
in Hindu than Muslim residents of Bali. Muslims are
strictly prohibited from eating or touching pigs, while
Hindus have no such restrictions.
When the prevalence of IgG anti-HEV was compared
among pregnant women in eight districts of Bali,
significant differences were found among them in a
range from 4.7% (4/86) in Tabanan to 32% (32/101)
in Gianyar. An even more striking difference was
noted in pregnant women between Hindus and nonHindus (mostly Muslims and a few Christians) (19%
[149/769] vs. 4.0% [2/50], P<0.012).
Since the religion of Bali is predominantly Hindu, a
random sampling of the Balinese would hardly reflect
the anti-HEV status in non-Hindus, as in the study of
Wibawa et al. [2004] and ours. Furthermore, the exposure
to HEV may be influenced by sanitary conditions and
water quality that differ in various areas of Bali. These
factors taken into considerations, pregnant women
living in a restricted area of Denpasar City (Sanglah) were
examined for evaluating the influence of religion on
HEV exposure. As the results, anti-HEV was significantly
more frequent in Hindus than Muslims (20% [20/102]
vs. 2.0% [2/101], P<0.001).
The observed differences in the prevalence of antiHEV would be attributed to distinct life-styles of the
Balinese in association with their religions. Among
Ford K, Wirawan DN, Reed BD, Muliawan P, Sutarga M. 2000. AIDS
and STD knowledge, condom use and HIV/STD infection
among female sex workers in Bali, Indonesia. AIDS Care
12:523–534.
Women in Bali appear to have been exposed to HEV
long before the pregnancy. The absorbancy for antiEV in ELISA was mostly low and HEV RNA was not
detectable in any of 20 sera with a high absorbancy
(>1.50). Hence, the risk of developing fulminant
hepatitis by HEV infection during the pregnancy
would be lower in Bali than in India [Kar et al., 1997].
Noto H, Terao T, Ryou S, Hirose Y, Yoshida T, Ookubo H, Mito
H, Yoshizawa H. 2003. Combined passive and active
immunoprophylaxis for preventing perinatal transmission of
the hepatitis B virus carrier state in Shizuoka, Japan during
1980–1994.
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many differences dependent on religions, those in
the dietary habit are prominent. Hindu families in
Bali typically keep pigs within the household, as a
source of food, and often eat grilled pork that can
be undercooked. In contrast, Muslims are rigorously
prohibited from tasting or even touching pigs
by their religion. Thus, it would be reasonable to
implicate close contacts with pigs, along with the
ingestion of domestic pork, in a high exposure to HEV
among Hindus living in Bali. Although ‘‘water-borne’’
transmission of HEV has been reported in Indonesia
[Corwin et al., 1997], the results obtained in this study
suggest an alternative mode of HEV transmission in Bali
that is ‘‘pig-borne.’’ In actuality, pigs in Bali are highly
contaminated with HEV; anti-HEV is detected in more
than 70% of them [Wibawa et al., 2004]. Furthermore,
zoonotic infections are common among children and
teenagers in Bali [Chomel et al., 1993].
Expanded Case Definition for
Diagnosing Extrapulmonary
Tuberculosis in HIV Infected Person
Evy Yunihastuti1
1
Division of Allergy and Clinical Immunology Department of Internal Medicine
School of Medicine University of Indonesia Ciptomangunkusumo Hospital,
Jakarta, Indonesia.
Acta Med Indones. 2006 Apr-Jun;38(2):103-4
237
A 30 years old male with a history of intravenous
drug user came with abdominal pain since 3 weeks
before admission. During the last month he lost 10
kg of his body weight. He had mild fever and night
sweat, without diarrhea or change in bowel habit.
He had not complaint any cough. He looked pale
and cachectic. Pulse rate was 100 times per minute
and axilla temperature was 37.2 C. Abdominal
examination revealed mild tenderness in epigastrium
without organ enlargement. His bowel sound was
normal. Laboratory findings were mild anemia (10.2
g/dL), low platelet count (120.000/dL), elevated ESR
(45 mm/h), and elevated CRP (102 mg/ dL). Liver
transaminase was normal. His anti-HIV was reactive
and anti-HCV was positive. CD4+ cell count was 45
cells/mL. Abdominal ultrasonography showed in
figure 1.
Biopsy of the paraaortic lymph nodes were
inconclusive. The patient then started standard
antituberculous regimen followed by antiretrovirus
four weeks after. The patient showed good response
to antituberculous treatment within the first six
weeks. Ultrasonography evaluation showed normal
paraaortic lymph nodes.
Expanded Case Definition for
Diagnosing Extrapulmonary
Tuberculosis in HIV Infected Person
Tuberculosis (TB) is the second commonest infection
among human immunodeficiency virus (HIV)
infected adults in Indonesia.’ Findings all possible
opportunistic infections before starting HAART
is one of the key success for HIV management.
Extrapulmonary tuberculosis (EM) comprises 1050% of all tuberculosis in HIV negative patients and
about 35-80% in HIV infected patients.2.1 The risk of
extrapulmonary tuberculosis and mycobacteremia
increases with advancing immunosuppression.4
The diagnosis of extrapulmonary tuberculosis in
HIV infected patients, especially in deeply located
inaccessible area, is often difficult. In resourcelimited settings, facilities for mycobacterial culture
and histopathology are often unavailable. These
facts make diagnosis of EPTB are often basal on
presumptive diagnosis. Wilson, et al had evaluated
expanded case definition for smear negative
pulmonary TB and EPTB in HIV infected patients
from WHO and South African National Guidelines.
The case definition for visceral lyrnphadenopathy is
visceral nodes (mediastinal/hilar or abdominal nodes
seen on imaging) PLUS fever >38C on two occasions
OR drenching sweats for >2 weeks, with positive
239
predictive value of 94%.5 This patient had abdominal
nodes and drenching sweats for 4 weeks and had
shown good improvement with antituberculous
treatment.
This case shown that the use of expanded case
definitions for the diagnosis of EPTB could be an
effective strategy in HIV-infected adults.
References
1.
Wigati, Karjadi TH. Yunihastuti E, lmran D, Rohmi S, Kusbiantoro
H. Spectrum of opportunistic infections among HIV infected
patients in Jakarta. Presented at: Australasian Society of HIV
Medicine Conference. Hobart, Australia August 2005. (yang ini
aku lupa bagaimana cara nulisnva)
240
2.
Golden MP, Vikram HR. Extrapulmonary tuberculosis: an overview. Am Fam Physician 2005;72:1761-8.
3.
Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J
Med Res 2004;120: 316-53
4.
Jones BE. Young SM, Antoniskis D, Davidson PT, Kramer F,
Barnes PF. Relationship of the manifestations of TB to CD4
counts in patients with human immunodeficiency virus infection. Am Rev Respir Dis 1993;148:1292-7.
5.
Wilson D, Nachega J, Morroni C, Chaisson R, Maartens G.
Diagnosing smear-negative tuberculosis using case definitions
and treatment response in HIV-infected adults. Int J Tuberc
Lung Dis 2006; 10(1): 31-8.
Correlation Between CD4 Count and Intensity
of Candida Colonization in The Oropharynx
of HIV-Infected/AIDS Patient
Ivo Novita Sah Bandar1
Djoko Widodo2
Samsuridjal Djauzi3
Abdul Muthalib4
Sidartawan Soegondo5
Retno Wahyuningsih6
1
Department of Internal Medicine.
2
Division of Infectious and Tropical Diseases.
3
Division of Allergy and Clinical Immunology.
4
Division of Hematology and Medical Oncology.
5
Division of Metabolic-Endocrinology, Department of Internal Medicine,
Faculty of Medicine, University of Indonesia / Cipto Mangunkusumo Hospital,
Jakarta.
6
Department of Parasitology, Faculty of Medicine, University of Indonesia /
Cipto Mangunkusumo Hospital, Jakarta.
Acta Med Indones. 2006 July-Sept;38(3):119-25
241
Abstract
Sexually Transmitted Diseases (STD continue to become major public health problems. Most of STD patients present with urethral or vaginal
discharge, even though the causes may be of different micro-organisms. The Syndromic Approach (SA) is ark algorithm for STD management
currently recommended by the WHO. Diagnosis are made based on clinical signs and symptoms using q certain flowchard-without laboratory
confirmation, and all possible causes will be treated. IEC are also given and the patients’ partners are notified. The East Java Provincial
health office has trained Puskesmas ‘and hospitals’ doctors and paramedics on this new STD management approach. The objective of this
study is to evaluate the implementation of SA in some Puskesmas and private clinics which personnels have been trained before. Using
direct observation, document research, interviews and focus group discussions, data and information on the benefit of SA, the obstacles
in implementing SA, and recommendations to improve the health providers’ performance in STD management are collected. Results are
hopefully used as inputs in improving the STD control program, provincially as well as nationally.
Introduction
HIV infection is indicated by qualitative and
quantitative reduction of T Helper (Th) cells.1,2 Clinical
manifestations of disease progressiveness usually are
associated with a reduction of CD4 count. Problems
for HIV-infected/AIDS patients usually start at the
time when CD4 count decreases, which indicates
various findings of opportunistic infection. One of
the problems is Candida Spp. infection.3,5-7
The genus Candida consists of more than 150 species.
Candida albicans is the Candida species that are most
commonly cause infection in human. Apart from C.
albicans, infection by Candida non C. albicans may also
found in HIV-infected/AIDS patients. Various studies
of HIV-infected/AIDS patients with oropharyngeal
candidiasis indicate that 9-10% isolates collected are
isolates of Candida non C. albicans and usually has a
poor response to Azoles, a class of anti-fungal drugs.8-12
In Indonesia, Cipto Mangunkusumo Hospital reports
that the prevalence of oropharyngeal and esophageal
candidiasis in HIV-infected/AIDS patients is about
80.8%.3 Another foreign report demonstrates similar
prevalence rates between Western and African countries for oropharyngeal candidiasis in HIV-infected/
AIDS patients, i.e. about 80-90%.11,13,14
Decrease in cellular immunity, indicated by reduction
of CD4 count in HIV-infected/AIDS patients, may
occur in systemic form, including decrease of cellular
immunity in mucosa of oropharynx. The decrease
is correlated to progressiveness of HIV infection.15
Reduction of CD4 count may cause decreased fungal
elimination. As the result, it causes imbalance of
Candida ecology and it increases Candida colonies.
Such increased colonies is an important factor to
initiate the process of oropharyngeal candidiasis.8,16-18
A study by Vargas et al demonstrates that there
is a significant correlation (p < 0.05) between the
high intensity of colonization in oropharynx and
oropharyngeal candidiasis in HIV-infected/AIDS
patients. It also demonstrates that there is no
correlation between CD4 count and the presence of
Candida colonies in the oropharynx of HIV-infected/
AIDS patients. Nevertheless. it did not study the
correlation between CD4 count and intensity of
candida colonization.17
So far, there are various studies on correlations
between CD4 count and oropharyngeal candidiasis
in HIV-infected/AIDS patients. However, correlations
between CD4 count and intensity of Candida
colonization in the oropharynx of HIV-infected/AIDS
patients have never been studied before. A patient
with oropharyngeal candidiasis will have more severe
clinical impact, such as reduction of food intake and
fluid intake, and it may aggravate the quality of life.19
The objective of this study is to know the correlation
between CD4 count and intensity of Candida The
243
Correlation Between CD4 Count and Intensity
of Candida Colonization in The Oropharynx
of HIV-Infected/AIDS Patient
younger age of HIV-infected/AIDS patients in
Indonesia may be associated with transmission
method. Most of HIV infection in young age is
transmitted through concomitant syringe usage
in intravenous drug user. This result is different
from study result conducted by Lydia27 in Cipto
Mangunkusumo Hospital in 1996, which indicates
that HIV infection is mostly transmitted through
sexual transmission for about 91%. This condition is
appropriate to national transmission rate of sexual
transmission at that time, i.e. 80.2%.27 When it was
found earlier in Indonesia, most of HIV infection
cases were caused by sexual transmission, but since
1999 the number of HIV/AIDS cases has increased
because the number of intravenous drug user has
also increased.1
In this study, we found a low CD4 count and total
lymphocytes count in most of subjects (61.67% of
CD4 count was less than 200 cells/iL and 65% of
total lymphocytes count was less than 1200 cells/iL).
These data were in accordance with previous studies
in Indonesia.20-22,27 The low CDT count and total
lymphocytes inthis study may be caused by the low
CDT count and total lymphocytes count in patients
when the first time they came to the hospital.
Most HIV-infected/AIDS patients in Indonesia come
to the hospital at the first time when their clinical
symptoms of opportunistic infection have occured
and at that time they already have a low concentration
of CD4 count of lymphocytes count.
The Prevalence of Oropharyngeal
Candidiasis
Oropharyngeal candidiasis in this study is found in
38 subjects (63.3%, 95% confidence interval of 51.1 75.5%). These data were lesser than the data of Cipto
Mangunkusumo Hospital which indicate oral and
esophageal candidiasis prevalence of 80.8%3. It is also
less than the study conducted by Lydia27 in Jakarta on
1996, which reports the prevalence of oropharyngeal
candidiasis in HIV-infected / AIDS patients is 90.9%
(95% confidence interval = 80.1 - 100,3). In Uganda,
other studies conducted by Ravera et al13 in a hospital
indicates prevalence of oropharyngeal candidiasis
for 90.8% (95% confidence interval = 87.6 - 94) in
HIVinfected/AIDS patients. In Michigan, The United
States of America, Sangeorzan et al18 found 83%
incidence rate of oropharyngeal candidiasis (95%
244
confidence interval = 75.93 - 90.7) in HIV-infected/
AIDS patients.
Lower prevalence of oropharyngeal candidiasis
was found in the study conducted by Teanpaisan
and Nitta Yananta28 in Thailand, i.e.; 66.66% (95%
confidence interval = 52.86 - 80.46). This difference
may occur because the latter study was performed
in the community and it was not performed in the
hospital.
Different prevalence data of previous studies
in Indonesia may be caused by unconfirmed
laboratory test, either by direct examination of
tissue speciment or by fungal culture. As a result,
the diagnosis was only based on clinical symptoms
and the sign of oral thrush in oropharynx. Oral
thrush is nearly always correlated to Candida Spp
infection. However, it is important to remember
that oral thrush is not always correlated to
oropharyngeal candidiasis.29,20
The frequency of oropharyngeal candidiasis in HIV
infected/AIDS patients is also determined by CDT
count. Oropharyngeal candidiasis is frequntly found
in patients with low CDT count, i.e. less than 200 cells/
iL.7,11 In this study we found Candida colonies’ growth
in CDT count with the range of 2 - 394 cells/iL and
most of oropharyngeal candidiasis occur in patient
with CDT count less than 200 cells/iL. Studies in
Uganda and Jakarta in 1996 shows lower mean value
of CDT count.13,27 However, the study by Moylet et al31
indicates that Candida Spp. infection may be found
initially in HIV-infected/AIDS patients with CDT count
less than 500 cells/iL. Thus, it can be seen that there
is a tendency of Candida colonies’ growth in patient
with higher value of CDT count eventhough it is not
as frequent as the growth in patient with lower value
of CDT count.
From the data above, we could see that
oropharyntigeal candidiasis is an infection frequently
found in HIVinfected/AIDS patients. Oropharyngeal
candidiasis is not included in CDC criteria as a
diagnosis for HIV/AIDS infection. However, the
revised WHO criteria for HIV/ AIDS cases includes
oropharyngeal candidiasis as minor criteria and it has
a high positive prediction value for diagnosis of AIDS
in Afrika.32.33 Moreover, oropharyngeal candidiasis is
also an indicator of HIV infection progressiveness.34
In this study, there are six subjects with Candida
colonization without oropharyngeal candidiasis.
The lowest CD4 count value of those subjects if
149 cells/iL. The highest number of colonies is 160
colonies/100iL. It ma be caused by immune system
of the host and the role of Candida virulence in
oropharyngeal candidiasis. So e strains of Candida
may produce enzymes such as phospholipase and
saps, which determine the viruten e potency of
Candida The other strains did not produce such
enzymes in adequate amount, which may ca se
infection .1,15,35
By using culture media of CHROM® agar, C. albicans
is the most frequently found species, which grows
from samples taken of subjects’ oropharynx, i.e.
44 isolates (74.6%). The other studies also indicate
similar tendency, i.e. domination of C. albicans as
the m. n cause of oropharyngeal candidiasis in
HIV-infected/ AI OS patients. In The United States
of America, Sangeorzan et al’s had studied 92 HIVinfected/AIDS patients and they found 81 % of
subjects with C. albicans infection. The other study
conducted by Sant Ana11 in Brazil also found C.
albicans as the most frequntly found Candida species
in oropharyngeal cavity of HIV-infected/AIDS patients
with oropharyngeal candidiasis, i.e. 91% of all isolates
found. In England, Carteledge et al10 also found 90%
C. albicans domination as the cause of oropharyngeal
candidiasis in HIV-infected/AIDS patients.
C. albicans produces protein in greater amount
compared to other species, which may help it to stick
on an, invade the damaged mucosa.8,19 Probably,
this has made C. albicans become a more frequently
found species as the causative agent of superficial
candidiasis, including oropharyngeal candidiasis in
HIV-infected/AIDS patients.
Fifteen isolates (25.4%) are Candida non C. albicans,
which have been identified through morphology
examination by using culture media of CHROM® agar.
Those fungi grow as colonies with nongre-n color
such as C. krusei, C. parapsilosis, and C. tropicalis. Most
of subjects have a low CD4 count an, most of fungi
found in patients with CD4 are less than 200 cells/iL
(93.3%).
These data are in accordance with the study
results, conducted by Cartledge10, Sant Ana11 and
Sangeorzan18. It occurs because Candida non C.
albicans has lesser virulence. Therefore, it needs lower
CD4 count to evoke infection. Candida non C. albicans
is associated with resistance of several anti-fungal
drug, especially fluconazole.10,11,18 It is reported that
C. krusei has primare resistance against fluconazole
treatment and C. glabrata is less sensitive against
fluconazole. Species identification may be applied
to estimate the sensitivity of fungal isolates against
anti-fungal drugs, which may help us to determine
the type of given drug.8,25
Correlation Between CD4 Count and
Intensity of Oropharyngeal Colonization
In the present study, we found a strong correlation
(correlation coefficient - 0.756) between the CD4
count and the number of Candida colonies which grow
from a mouth-rinse sample of subject’s oropharynx.
The lower CD4 count, the higher number of colonies
grow in a subject’s mouth-rinse sample. Until now,
there is no study which correlates those facts.
Various studies indicate that there is a correlation
between reduced cellular immunity in the host (in this
case, the decrease of CD4 count) and oropharyngeal
candidiasis.18,31,36,37
Imam et a137 found that in female HIV-infected/
AIDS patients, oropharyngeal frequently occured in
patient with mean value of CD4 count of 230 cells/
iL (p value 0.0001). The present study also indicates
oropharyngeal candidiasis as the most common
opportunistic infection in those study subjects and it
reccures frequently in patient with severe reduction
of cellular immunity.37 Sangeorzan et al18 indicates
CD4 count less than 200 cells/L is correlated to oral
thrush in HIV-infected/AIDS patients.
Leigh et al37 studied about immune reactivity of HIVinfected/AIDS patients against Candida antigen.
Immune reactivity against Candida antigen decreases
in patient with CD4 less than 200 cells/iL. In this
study, the highest value of CD4 count of subjects
with oropharyngeal candidiasis is 394 cells/iL. In
those subjects, we found clinical manifestation such
as dysphagia and difuse erythema in oropharyngeal
cavitiy and 280 colonies of positive culture are
found.
245
Colonization and Oropharyngeal
Candidiasis
Herdiman T Pohan1
1
Division of Tropical-Infectious Disease, Departement of Internal Medicine,
Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital,
Jakarta.
Acta Med Indones. 2006 July-Sept;38(3):169-73
247
Opportunistic Infection of HIV-Infected/AIDS
Patients in Indonesia: Problems and Challenge
Abstract
Infectious diseases are one of the biggest healthproblem in the world, while HIV/AIDS itself ranks second in mortality. The latest situation shows
a remarkable increase of HIV/AIDS cases in Indonesia. About 90.000 to 130.000 people in Indonesia arc predicted of being infected with HIV
nowadays. HIV may progress to AIDS as patient’s immune status decreases. As well to the condition, opportunistic infections will occur and
eventually it may lead to death. An efficient and effective approach in early detection and proper management of opportunistic infections,
followed with sufficient anti retroviral administration, may reduce mortality. Other approaches in managing HIV/AIDS and opportunistic
infections are needed to support a complete and holistic management for patients with HIV Full participation from family, medical experts,
government and public is strictly a must to overcome this problem.
Key words: HIV, AIDS, opportunistic infections.
Introduction
Infection is a major global health problem in
developed and developing countries. In developing
countries, the problem is “more complicated and
associated with various social and economic
problems. Among all infectious diseases, the greatest
problem includes infection of respiratory lower tract,
HIV/AIDS, diarrhea, tuberculosis and malaria. The
world’s HIV/ AIDS pandemic is a great challenge in
the 21st century. 1,2
Actually, the AIDS patient usually died because of
opportunistic infection and not by the HIV itself
directly. This fact encourages me to explore further
about problems of HIV infection.
First, please allow me to quote the utterance of
Professor Zubairi Djoerban in his affirmation speech,
i.e. he reminded and suggested us to discard the
terminology of AIDS patient and substitute it with
the terminology of people with AIDS/Odha (orang
dengan HIV/AIDS) so the AIDS patient will be treated
more humanly, as a subject and not as an object or as
patient with certain stigma.1
HIV infection was first recognized in 1981, since
then the amount of HIV/AIDS cases in the world
keep increasing significantly. During the next two
decades the amount of HIV cases in the world is
estimated about 40 million people, and only in the
next four year, the amount will be twofold. Based on
those estimations, the amount of people with AIDS
in the world recently was predicted approximately
60 million people.2,3,4 The total mortality rate of HIV/
AIDS reported in 2004 was almost about 25 million
people.
Indonesia as an archipelago country in South East
Asia, also deals with that danger. The WHO data
in 2003 indicated that Indonesia is on the 4th rank
country, which has the most rapid growth of HIV
infection cases. This statement is supported by the
report of CDC Directorate General about the amount
of HIV/AIDS cases in Indonesia. At the end of 2001,
the amount of recorded data was 2575 cases. Based
on the last three-month report, until the end of
September 2005, the accumulation of those cases
increased up to 8,251 cases.5
Indeed, the amount of recorded data is much lesser
than the actual amount. It is caused by a poor recording
and reporting system in the hospital and other health
services. As an estimation, the Department of Health,
Republic of Indonesia together with UNAIDS predict
the number of Indonesian citizen with HIV infection
is ranged between 90,000-130,000 people.2,3,4
However, according to statistical data of National
Narcotics Committee, the number of narcotics userr
with syringe needle at the end or year 2005 is about
572,000 people and 60% of them (approximately
340,000 people) is estimated as HIV positive. This
number certainly does not include the number of
HIV patient infected through sexual transmission and
HIV maternal-fetal vertical transmission. These facts
indicate that Indonesia has been on initial phase of
AIDS epidemic.6
249
Opportunistic Infection of HIV-Infected/AIDS
Patients in Indonesia: Problems and Challenge
Recently, HIV/AIDS has been a global problem and
it does not exist merely as health problem but it
also associated with economic and social problem?
Indeed, this fact will have major effect to the country.
The advanced physical and human resources
development, which has been established for years
may be vanished because the country has lost a great
number of skilled and educated human resources.1
we should remember the basic principal of diagnosis
acid treatment for opportunistic infection in patient
with AIDS, so either medical personnel or people
with AIDS will not feel desperate. Furthermore, as we
have known, “prevention is better than treatment”,
therefore the prevention aspect of opportunistic
infection should be concerned and become a
priority.
AIDS and The Problem of Opportunistic Infection
Opportunistic Infection: The Current
Challenge
Advanced HIV infection is known as AIDS, which
is characterized by opportunistic infection.
Opportunistic infection is defined as an infection
occurs due to decreased immunity system. This
infection may occur through new infection by other
microorganism (bacteria, fungi, and virus) or through
reactivation of latent infection, which in normal
condition it is controlled by the immune system.8
A HIV-infected patient initially was asymptomatic
and later the clinical manifestation appears because
of immunologic impairment. Clinical manifestation
in AIDS is numerous, from mild clinical manifestation
to severe manifestation, which has a fatal potency.
Opportunistic infection has been proven causing
death in more than 90% patient with AIDS.9
According to the data from Directorate General of
CDC until late September 2005, the most common
opportunistic infection in patient with AIDS recently
is candidiasis, followed by tuberculosis and other
opportunistic infections such as fungal infection,
herpes, toxoplasmosis and CMV.5 The knowledge
about clinical spectrum of AIDS indicates that
opportunistic infection is associated with the number
of CD4 cells.
Opportunistic Infection: Treatment And
Prevention
Principally, the treatment of opportunistic infection in
patient with AIDS is inseparable from treatment with
antiretroviral (ARV) drugs. Both components should
be given concomitantly and as a synergy, because one
will support the other efficacy. In certain condition,
the treatment of opportunistic infection should be
given first, and later followed by ARV administration.
By treating the opportunistic infection first, it will
prevent mortality in people with AIDS.
Dealing with opportunistic infection treatment in
people with AIDS is not easy, we often fail. Therefore,
250
The major challenge in the management of
opportunistic infection is initiated by difficulty to
diagnose a HIV/ AIDS new case early. Ironically, when
there is a suspicion of HIV/AIDS or when diagnosis of
HIV/AIDS has been established, usually people with
AIDS already have clinical manifestation, because
those symptoms lead them to the health care unit..
If patient with AIDS has experienced this stage,
then he/she already had an opportunistic infection
and advanced condition, or we may say that his/her
condition will be more difficult to be managed.
Generally, opportunistic infection involved multiple
pathogens which attack simultaneously. Therefore,
we need a strategy for diagnosis and treatment by
using antimicrobial, which usually have to be given
in combination form. The selection of antimicrobial
drugs is preferably adjusted with the diagnosis ad
pathogen of causative agent; but in clinical setting,
the treatment usually is given empirically because of
difficulty and limitation in diagnosis equipment. The
other problem is ARV treatment may have a potency
of drug interaction with antimicrobial given for
treatment of opportunistic infection.
Moreover, the other important problem is drug
availability and treatment cost because it will
affect the therapeutic achievement. The episode of
opportunistic infection treatment is relatively longer
because the antimicrobial drugs given are not only
for therapy but also function as primary or secondary
prophylaxis.10
Stigma And Discrimination: Unprpared
Community And Medical Personnel
When International AIDS Conference on Critical
Themes for AIDS in South Asia was hold in Bangkok,
Thailand in 2004, the issue about stigma and
discrimination to people with AIDS and the gender
issue still become two largest challenge of AIDS
To date, there are two epidemic hazards that keep
spreading, the first one is AIDS, and the second
is stigma and discrimination attached to people
with AIDS.11,13 When stigma arises, the community
and including people with AIDS naturally will try
to ignore the fact that they may be infected by HIV
This condition will increase risk of rapid disease
development and also the risk of contamination to
the other.
The United Nations Population Fund (UNFPA) in
2003 revealed that the main reason for lack of
resources against HIV/AIDS is persistence stigma
and discrimination in people with AIDS. Violation
of human rights drives the development of this
disease.14
HIV/AIDS does not only affect physical condition in
people with AIDS but also their mental condition.
HIV/ AIDS may cause anxiety and depression, or even
dementia and psychosis. Of course, it will affect their
quality of life.1
Various refusal acts to treat people with AIDS still
occur in hospitals. Unprepared medical assistance
in treating opportunistic infection and HIV/AIDS is
very important for management quality of people
with AIDS. Opportunistic infection which should be
treated or minimized had become neglected. Various
feeling of unfair treatment, isolation, insult, the ability
of medical staff which is not well distributed, and
refusal acts to treat people with AIDS will aggravates
their health condition.
Suggestions For Solving Problem: What
Can Be Done?
The situational report of UNFPA in 2005 proclaim to
the world leaders to fulfill the agreement of equality
and equivalent dignity in various life aspects for
women and girls of various race, religion, groups,
and class. If not, poverty will become a history and
the goal of improvement will not be achieved.12
The agreement of equality and equivalent
dignity poured out in the objective of Millennium
Development Goals (MDGs). We expect that it would
be able to be implemented in the next 2015. There are
8 important programs that should be implemented;
one of them is fight against HIV/AIDS. The effort of
fighting against HIV/AIDS and the other diseases is
included on the 6th point. It has an objective that the
world is able to stop the growth rate and reverse the
disease spread in 2015.15
The world’s AIDS day on 1 December is a precious
moment that should be appreciated so that it may
increase the community awareness and concern
about HIV/AIDS elimination. This opportunity may
become a trigger for implementation of HIV/AIDS
program and it will be implemented continuously.
In order to overcome HIV/AIDS spread and pandemic,
prevention effort is the main concern. If HIV infection
can be prevented, the opportunistic infection will
be automatically prevented. Various efforts of HIV
infection suggested by WHO for developing countries,
actually has been successfully implemented in
Indonesia. Unfortunately, those programs have not
been continuously implemented and it has been not
welldistributed in all over Indonesia.1
Early Diagnosis Effort And Treatment
Evaluation
The best method to increase clinical ability and
early precaution for HIV/AIDS and opportunistic
infection is through education about those topics for
medical profession. Specific course about HIV/AIDS
in curriculum for undergraduate and postgraduate
medical students, post graduate of other biomedical
fields is obviously necessary. Moreover, there should
be a continuous medical education for medical staff
in order to renew knowledge and to get the current
information. Such continuous medical education
should be carried out by everybody including
students, doctors, nurses, and educational staff in
university, government and private sectors. For HIV/
AIDS, everyone should be able to cooperate and help
each other to create a good National Health Service
System.
Commitment Declaration of UN General Meetings
of HIV/AIDS in 2001 declared that care, support
and treatment are the basic component for every
human.16 In order to support the commitment,
Department of Health, Republic of Indonesia in 2003
has published a book of “National Guidance of health
care, support and treatment for people with HIV/
251
prevention in South Asia” Poverty, discrimination,
and violence have made women vulnerable to HIV
infection, therefore half of 40 million people with HIV
are women.12
AIDS. It is intended to provide overall description for
the health care personnel and the community, and it
is expected to be able to motivate them to carry out
the health care, support and treatment for people
with HIV/AIDS.16
This guidance book should be properly well
distributed to all of health services unit in Indonesia
and to be implemented further for management of
HIV/AIDS cases. The function of referral hospital for
HIV/AIDS is to guide and monitor the management
of this case. The availability of diagnostic equipment/
simple examination with reasonable cost is extremely
required for diagnosis; at least it should be available
in all of referral hospital for HIV/AIDS.
A good coordination between National Committee
of AIDS Management and the Regional Committee
of AIDS Management should be well-developed, and
it should involve the referral hospital for HIV/AIDS
and the primary health care unit/puskesmas. In order
to facilitate this process, an easy and fast referral/
consultation system should be available to facilitate
the referral process of management for people with
HIV/AIDS.
Access, Interaction, Drug Cost And
Treatment Compliance
Availability, access and drug distribution for
opportunistic infection and HIV/AIDS have a very
important role in successful treatment for people
with HIV/AIDS.
The treatment cost is still a complicated problem, but
the sincere government commitment to overcome
HIV/ AIDS problem and opportunistic infection is
expected to be able to motivate pharmaceutical
industries to increase local / generic drugs
production with less expensive price compared
to imported drugs. Hence, the treatment cost that
should be endured by the people with HIV/AIDS can
be minimized.
In monitoring drug distribution the Department of
Health is expected to improve coordination with the
Health Official Services and Local Government in
order to assure a well-distributed drug distribution.
Institution of Self-Supporting Community concerning
on HIV/AIDS, which has a lot participation in the
management of HIV/ AIDS cases, such as Pelita Ilmu
Foundation, the Working Group on HIV/AIDS and
252
National Movement of Improving Therapeutic Access
for HIV/AIDS (GN-MATHA), should be continuously
utilized. As a reward of appreciation and a facility to
preserve motivation, the government appreciation
will be given periodically based on performance of
related Institution of Self-Supporting Community in
certain period of time.
The development of ARV treatment in Indonesia since
1999 has brought consequences of drug availability
for ARV drugs in 25 hospitals in all over Indonesia
since July 2004.17 According to CDC Directorate
General, they are trying to add the amount of
availability drug up to 75 hospitals. The availability
of ARV drugs is correlated to Indonesian sincere
concern and commitment to be actively involved
in HIV/AIDS management, in keeping with 3 by 5
treatment proclaimed by WHO since April 2004.17
The Community Preparation:
Minimize Stigma And Discrimination
Community participation is one part of important
factor for succeeding treatment series for patient
with HIV/ AIDS. Sharing knowledge about HIV/
AIDS should be conducted so that there is no more
misunderstanding of this problem in community.
Individual counseling support is necessary to
overcome this problem.
Furthermore, supporting effort and legal government
support is also necessary to overcome the problem
of stigma and discrimination. Legal provision
concerning human rights of people with HIV/AIDS
is extremely essential in order to assure effective
response in controlling this epidemic.14
Preparation Of Medical Personnel And
Centralization Efforts On Health Care
Services
Organizing an integrated health care centre for
people with AIDS is one of several attempts to
enhance the health care services for people with AIDS.
This centre will make a more focus and coordinated
health care services for them. It should be equipped
with adequate health care facilities including
comprehensive universal precaution supported
by professional medical personnel and adequate
medical ward. The term of “HIV/AIDS infection” should
be avoided and it should be substitute by the term
of “specific infection” in order to prevent ostracized
impression.
3.
Djoerban Z. HIV/AIDS di Indonesia: masa kini dan masa depan.
Pidato pada acara pengukuhan guru hesar tetap dalam
ilmu penyakit dalam pada Fakultas Kedokteran Universitas
Indonesia. Jakarta: 20 Desember 2003.
4.
Adler MW. Development of the epidemic. In: Adler MW, ed. ABC
of AIDS. 5’1 ed. London: BMJ Publishing Group; 2001. P. 1-5.
5.
Astoro NW, Djauzi S, Djoerban Z, Prodjosudjadi W. Kualitas hidup
penderita HIV dan faktor-faktor yang mempengaruhi [Disertasi
Program Pendidikan Dokter Spesialis Ilmu Penyakit Dalam].
Jakarta: Fakultas Kedokteran Universitas Indonesia; 2003.
Conclusion
6.
Vernawati SA. Pemanfaatan layanan konseling dan tes HIV
sukarela di Puskesmas Kelurahan Kampung Bali Jakarta dan
hubungannya dengan kebijakan pemerintah mengenai akses
antiretroviral untuk semua [Tesis Program Pndidikan Dokter
Spesialis 1 Ilmu Penyakit Dalam]. Jakarta: Fakultas Kedokteran
Universitas Indonesia; 2005.
7.
Ditjen PP&FL Depkes RI. Statistik kasus HIV/AIDS dan infeksi
oportunistik di Indonesia: Dilapor s/d September 2005.
Jakarta: Depkes RI; 2005.
8.
Anonim. Indonesia fase awal epidemi. Kompas, 29 November 2005.
9.
Widodo D. Isu terkini di bidang penyakit tropik & infeksi.
In: Setiati S, Aiwi I, Simadibrata M, Sari NK, editors. Naskah
lengkap pertemuan ilmiah tahunan ilmu penyakit dalam
2004. Jakarta: Pusat Penerbitan Departemen Ilmu Penyakit
Dalam FKUI; 2004. p. 99-108.
There are some basic requirements for a success
HIV/AIDS management and prevention program at
national level. First, there is government’s political
enthusiasm and leadership to implement the
program. Coordination with international institution/
organization facilitating the program fund and HIV/
AIDS training should be ‘enhanced continuously.
Coordination is extremely necessary in order to
optimize our limited ability for HIV/AIDS program.1
Second, partnership and active participation of the
whole community, not only by medical and health
care society but also the religion leaders, family,
activist, students and private society, should have
contribution in every stage of program planning and
implementation.
Third, there is a source of fund to perform various
activities.1
Fourth, a correlation between prevention and
supporting effort / treatment and care should be
concerned. Fifth, a program proclaimed for social
context should be applicable. Sixth, we have to
strengthen the community acceptance against people
with AIDS and, seventh, those programs should be
completed involving multi sector disciplines.1
Ultimately, we have:, to understand that HIV/AIDS
is not merely a responsibility for doctors and nurses
but it is a responsibility for all of us: whatever we are,
for any social class, religion or political orientation.
AIDS is a problem for all of us and we can not delay
its solution. We have to begin management steps
directly when we realize the epidemic threat of this
disease. If not, everything will be too late.1
References
1.
The world health report 2000. Health systems: improving
performance. Geneve: World Health Organization; 2000.
2.
The report of HIV/AIDS epidemic 2002. Geneve: World Health
Organization; 2002.
10. The American Heritage® Stedman’s Medical Dictionary.
Houghton Mifflin Company, 2002. [Diakses 7 Desember 2004]:
Tersedia di: URL: http://dictionary.reference.com/search?q=
gvpotunistic+infection r&67.
11. Lydia A. Hitung limfosit total sebagai prediktor hitung limfosit
CD4 pada penderita AIDS. [Tesis Program Pendidikan Dokter
Spesialis I Iimu Penyakit Dalam]. Jakarta: Fakultas Kedokteran
Universitas Indonesia;1996.
12. Kovacs JA, Masur H. Prophylaxis against opportunistic
infections in patients with immunodeficiency virus infection.
N Eng J Med 2000;342(19):1416-29.
13. UNAIDS.org [homepage di internet]. Geneva: Stigma Biggest
Hurdle to AIDS Prevention in South Asia. Satellite session at XV
International AIDS Conference on critical themes for AIDS in
South Asia; [dibuat 13 Juli 2004, diakses 13 Okt 2005] Tersedia
di: http://www.unaids.ora/.
14. Anonim. Menagih janji para pemimpin. Kompas, 17 Oktober 2005.
15. UNAIDS.org [homepage di internet]. Geneva: Stigma and
discrimination; [dibuat Des 2003, diakses 13 Okt 2005].
Tersedia di: http://www.unaids.org/.
16. UNFPA.org [homepage di internet]. Geneva: stigma and
discrimination Stymie AIDS Prevention Efforts; [dibuat I Des
2003, diakses 13 Okt 2005]. Tersedia di: http://www.unfoa.
org.
17. UN.org [homepage di internet], Millennium Development
Goals; [dibuat 2005, diakses 13 Okt 2005]. Tersedia di: http://
www.un.org/millenniumgoals/.
18. Ditjen PPM & PL Depkes RI. Pedoman nasional - perawatan,
dukungan dan pengobatan bagi Odha. Jakarta: Departemen
Kesehatan RI;2003.
19. Djauzi S, Djoerban Z, Yunihastuti E, Karjadi T, Rachmadi K.
Organization of HIV care in Indonesia, workshop PK/PD and
tolerability of antiretroviral drugs an approach to optimalization
of treatment, The 6’s Jakarta Antimicrobial Update. Jakarta:
Dutch-Indonesian workshop on HIV-treatment;2005.
20. Djauzi S, Rachmadi K. Self reliance on the move (based on
experiences of the working group on HIV/AIDS of University
of Indonesia in providing greater access to generic ARV drugs
in Indonesia). Jakarta: The Working Group on HIV/AIDS, Faculty
of Medicine, University of Indonesia-Dr. Cipto Mangunkusumo
General Hospital and The Indonesian Perspective Group. 2004.
253
Continuous medical education and various courses
to change behavior and enhancing capability of
medical personnel in providing health care services
for patient / people with AIDS should be conducted so
that every medical personnel has at least a necessary
standard capability to provide a health care services
as mentioned above.
Changes of Opportunistic Infection Pattern
in Patients with AIDS in Jakarta
Samsuridjal Djauzi1
1
Division of Allergy-Clinical Immunology, Department of Internal Medicine,
Jakarta.
Acta Med Indones. 2006 Jul-Sep;38(3):117-8
255
The outpatient clinic of special study group on AIDS
Abstract FKUIJRSCM provides health service for
(POKDISUS)
most of patients with HIV infection/AIDS in Jakarta.
According to information center currently there are
approximately 1800 cases and most of them (67%)
are intravenous drug users.1
The study to obtain the profile of opportunistic
infection in hospital had been initiated by Aida et
al (1999). The pattern of opportunistic infection
reported by Aida was the 1st report on opportunistic
infection pattern in Indonesia. Aida et al reported
fungal infection of gastrointestinal tract was the
most frequent infection followed by tuberculosis.
Cytomegalo retinitis was also an important
opportunistic infection reported by Aida. Compare
to opportunistic infection pattern in developed
countries, in Cipto Mangunkusumo hospital,
however, Pneumocystic Carinii Pneumonia (PCP)
was not common. Case series reported by Aida were
HIV patients who were infected likely due to sexual
transmission because intravenous drug user was
still uncommon phenomenon in Indonesia.2
Maulana et al (2002) reported the opportunistic
infection pattern in Cipto Mangunkusumo hospital
and showed that fungal infection of gastrointestinal
tract was still the most frequent infection. At that
time, most of cases were intravenous drug users.3
Yunihastuti reported 698 cases in 2004 and found
that fungal infection of gastrointestinal tract was
48% of all cases followed by lung tuberculosis (36%)
and chronic diarrhea. Case series by Yunihastuti
demonstrated relatively high incidence of lung
tuberculosis infection (17%) and if it were put together
with extra-lung tuberculosis infection accounted
for 50% of all cases. Thus, according to this report,
tuberculosis was the most common opportunistic
infection. However, it reported cytomegalo retinitis
less then those reported by Aida.4
The diagnosis of opportunistic infection is important
because anti retroviral treatment (ARV) should be
given between 2 weeks and 2 months after giving
anti tuberculosis treatment. Concomitant treatment
of anti tuberculosis and ARV would increase risk of
nausea, hepatotoxicity and immune reconstitution
syndrome/ immune restoration disease). Immune
reconstitution syndrome is a syndrome which occurs
due to inflammation process because of immune
system restoration. One of etiology of immune
reconstitution syndrome is tuberculosis. 5-6
Diagnosis of opportunistic infection in most of the
case was still a presumptive diagnosis. Confirmation
of diagnosis is certainly necessary to find the cause
of opportunistic infection.
Karyadi et al reported that parasite infection was
the cause of chronic diarrhea in HIV-infected
patients. The study reported 150 cases and the
most common parasite found was Blastocytis
hominis. As the etiology of chronic diarrhea, the
role of B hominis was still controversial whether
this parasite was commensally or pathogenic.
However, one case reported by Karyadi found B
hominis in ascitic fluid and the patient was die. 7
Sahbandar reported in this journal that colonization
of Candida in the oropharyng in patients with AIDS.
It revealed that C albicans was the most commonly
found species in this study. In this case series,
subjects were either hospitalized or outpatient clinic,
so the median of CD4 was still high 100 cell/uL.8 In
fact, CD4 of hospitalized patients was far lower than
outpatient subjects. Mahdi found median of CD4
count of hospitalized patient in Dharmais hospital
was 36 cell/uL.9 A study by Sahbandar showed the
strong negative correlation between intensity of
Candida colonization in oropharyng of HIV patients
and their CD4 count. Unfortunately in this study,
pattern of Candida resistant to fluconazole was not
investigated. The data is important since fluconazole
is the main drug used for Candida opportunistic
infection in Indonesia.
257
Changes of Opportunistic Infection Pattern
in Patients with AIDS in Jakarta
References
1.
Data Poliklinik Kelompok Studi Khusus (Pokdisus) AIDS FKUU
RSCM Januari 2004-Juni 2006.
2.
Lydia A. Hitung limfosit total sebagai prediktor hitung limfosit
CD4+ pada penderita AIDS [tesis]. Jakarta: Program Pendidikan
Dokter Spesialis-1 Departemen Ilmu Penyakit Daiam Fakultas
Kedokteran Universitas Indonesia; 1996.
3.
Suryamin M. Hitung limfosit total sebagai indikasi memulai
terapi antiretroviral pada pasien HIV/AIDS [tesis]. Jakarta:
Program Pendidikan Dokter Spesialis-1 Departemen Ilmu
Penyakit Dalam Fakultas Kedokteran Universitas Indonesia;
2002.
4.
Yunihastuti E, Karjadi TH, Wigati, et al. Opportunistic
infections among HIV infected persons in Jakarta. Presented
at Australasian Society of HIV Medicine Conference 2005,
Hobart, Tasmania
5.
French MA, Price P, Stone SF Immune restoration disease after
antiretroviral therapy. AIDS 2004; 18: 1615-27.
258
6.
Lawn SD, Bekker LG, Miller LF Immune reconstitution disease
associated with mycobacterial infections in HIV-infected
individuals receiving antiretrovirals. Lancet Infect Dis 2005; 5:
36173
7.
Karjadi TH, Kurniawan A, Yunihastuti E. Parasites in
chronic diarrhea among people living with AIDS in
Ciptomangunkusumo Hospital Jakarta. (unpublished data)
8.
Sahbandar IN. Correlation between CD4 count and intensity
of candida colonization in the oropharynx of HIV-infected/
AIDS patient. Acta Med Indones. 2006:38(3);119-25.
9.
Mahdi I. Analisis kesintasan pasien AIDS selama 1 tahun yang
mendapat ARV dengan CD4 < 200 di RS Kanker Dharmais.
[tesis]. Jakarta: Program Pendidikan Dokter Spesialis-1
Departemen Ilmu Penyakit Dalam Fakultas Kedokteran
Universitas Indonesia; 2005.
Pneumothorax in HIV-Infected Babies
Translated from Pneumotoraks pada Bayi yang Terinfeksi HIV.
Grace Simatupang1
Abraham Simatupang2
Leopold Simanjuntak1
Ida Bagus Eka1,2
1
Department of Child Health, Medical School, Christian University of Indonesia,
Jakarta.
2
Special Working Group on AIDS, Medical School, Christian University of
Indonesia, Jakarta.
Maj Kedok FK UKI 2007; Apr-Jun 25(2):44-9
259
Introduction
Human Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome (HIV/AIDS) infection was first
reported in the United States in 1981, affecting
homosexual adults. In 1983, it was reported in children.
Just six years later (1989), AIDS became a disease
threatening children in the United States. Right now,
AIDS causes more than 8000 deaths per day, which
translates to one person every ten seconds. Because of
that, HIV infection is seen as the infectious agent that
causes the highest number if deaths, all by it’s own.
According to the Joint United Nations Program on
HIV/AIDS (UNAIDS) estimates, there are cumulatively
39,4 million people in the world with HIV/AIDS. As
much as 17,6 million (45%) of them are women and
2,2 million are children. Throughout the year 2004, it
was estimated that 640.000 children suffer from HIV/
AIDS (about 1750 cases/day).
WHO have warned Indonesia of the country’s HIV/
AIDS infection increase rate that currently ranks third
in the world. Cumulatively in Indonesia, the HIV/AIDS
population from January 1st, 1987 to March 31st,
2007 consists of 5460 individuals who have been
infected with HIV and 8988 who have entered the
AIDS stage. The total is 14.628 with the number of
deaths at 1994.
Physical examination results on admission were as
followed: patient looked very sick, trouble breathing,
not pale, and no cyanosis on the fingertips and
lips. Weight was 3,7 kg and body length was 61 cm,
breathing frequency was 70 times per minute, there
was a nasal pinch breathing, heart rate was 150 times
per minute, regular, and temperature (axillary) was
36,5°C. Conjunctiva was not pale and sclera was not
icteric. No abnormalities were found in the ears, nose,
and throat. Suprasternal, intercostal, and epigastrical
retraction could be seen. The right phremitus stem is
weaker than the left. The lower right hemi thorax was
hyprsonor, and the upper left and right hemithorax
was dull. Basic breathing sound was vesicular, and
the I-II heart sound was normal; noise and flutter
were not heard. Abdomen was weak, not enlarged;
turgidity was enough; heart and spleen not palpable;
normal peristaltic sound; acral extremity was warm.
Blood gas analysis performed when the patient was
first treated shows signs of hypoxemia. It was treated
with oxygen administration at 2 liters per minute.
Peripheral blood, urine, and feces examination results
were within the normal range (Table 1).
Case Report
The thorax image shows shadowing on the left lung
and a bit on the right. Right costophrenical sinus is
dull and the lower lobe of the right lung collapses—
findings suggesting of left lobular pneumonia and
right pneumothorax (Picture 1).
A two months old male baby suspected of HIV
infection with pneumothorax and pneumonia was
referred to FK UKI Public Hospital. Past medical
history includes coughing for three days with fever
and breathlessness. Patient was born prematurely,
spontaneously, helped by a physician in a hospital
with a birth weight of 2000 g and 52 cm body length.
The patient receives breast milk for four days before
he was given formula milk.
Based on the mother’s history of HIV infection,
clinical manifestations, thorax imaging, and HIV-1
RNA and CD4 tests results, the patient was diagnosed
with AIDS and suspected of pneumothorax and
pneumonia opportunistic infection (OI) of unknown
etiology. Patient was given a therapy of 1B caen
parenteral fluid with maintenance drops and a diet
of 6 x 20 cc formula milk by nasogastric tube (NGT).
Patient is a first child, born from a father with a
history of drug use since high school but who never
test himself for HIV. The mother has HIV but she never
receive antiretroviral (ARV) therapy. Three weeks after
he was born, the patient’s mother died of coughing
and breathlessness.
The major problem in this patient was the pneumonia
and pneumothorax that had not been treated,
causing dyspnea. So the patient was then treated
with oxygen at 2 litres per minute, 2 x 180 mg of
cefotaxim, and 185 mg of metronidazole. Usage of
water shield drainage (WSD) was also planned.
261
Pneumothorax in HIV-Infected Babies
Consultation was made to the POKJA HIV-AIDS RSU
FK-UKI, who advised the addition of 2 x ½ teaspoon
of cotrimoxazole and the replacement of cefotaxime
with 2 x 40 mg meropenem.
After conservative treatment for eight days, patient
condition deteriorated. The physical examination
findings are: patient looked weak; dyspnea; nasal pinch
breathing; intercostal, suprasternal, and epigastrical
retraction; heart rate 162 times per minute; breath rate
94 times per minute; temperature (axillary) 37,2°C. A
second thorax imaging shows signs of worsening
compared to the previous imaging (Picture 2). Patient
was consulted to the surgery department and WSD
application was decided, provided the family agree.
A day after the application of WSD, the patient
general condition seemed better. Patient did
not seem to have trouble breathing; no cuping
hidung breathing; heart rate 140 times per minute,
regular; breath rate 140 times per minute, regular;
temperature (axilla) 36,5°C. Thorax imaging showed
signs of improvement. The therapy on this patient is
still continued (Picture 3).
Discussion
In babies and children, the major cause of HIV infection
is vertical transmission, either during pregnancy, when
birth, or during breast-feeding. If no intervention is
done to an HIV-positive pregnant woman, the risk of
mother-to-infant infection is 25-45%. 2,6,7
In developed countries, the risk of mother-to-infant
HIV transmission has decreased to about 1-2%, thanks
to advanced interventions for HIV-infected pregnant
woman, including counseling services, voluntary HIV
tests, ARV administrations, elective caesarian section
birth using Misgav Ladach technique (fast operation
technique; opening to closing no more than 20
minutes)7 and formula milk feeding.
Factors that cause HIV transmission from mother to
infant are high viral loads (more than 100.000 copy/
ml), low number of CD4 cells (less than 200), virus
characteristics, microbial infections, pervaginam
labor, premature rupture of membrane, intrapartum
bleeding, breast feeding, premature birth (<34 week),
low birth weight and wound in the baby’s mouth.
A baby born from an HIV-infected mother may not
receive infection during pregnancy and labor, but
262
could be infected through breastfeeding. The longer
the breast milk is given, the higher the cumulative
risk of HIV transmission from mother to infant. On
the first five months of breastfeeding (since birth),
the transmission risk is estimated at 0,7% per month.
Between 6-12 months the risk is 0,5% per month
and between 13-24 months it increased again as
much 0,3% per month. Decreasing the duration of
breastfeeding could decrease the risk of the baby
getting HIV infection.
The patient was born prematurely, spontaneously,
with a birth weight of 2000 grams. He consumed
breast milk for four days from the mother, who has
HIV, and never receive ARV therapy. On the physician’s
suggestion, breast milk was stopped and replaced
with formula milk. The termination of breast milk in
this patient is very correct because breastfeeding
could increase the risk of transmission, but other risk
factors that couldn’t be evaded are spontaneous birth,
premature birth, and low birth weight. Therefore, in
this patient the HIV transmission probably happened
during pregnancy and labor.
The clinical manifestations of HIV-infection on a
child highly vary. WHO divides the clinical criteria
for HIV infected suspects on child by observing the
accompanying secondary infections and the child’s
nutritional growth.
HIV infections that are possible on children are recurrent
infections such as pneumonia, sepsis, cellulitis in 12
months, oral thrush (erythema or pseudomembrane on
the mouth area, tongue, and cheek), chronic parotitis,
generalized
lymphadenopathy,
hepatomegaly
without a clear cause, recurrent infections (>38°C) more
than seven days, neurological dysfunction (mental
disorders, microcephaly, hypertonia), herpes zoster,
and dermatitis HIV (fungal infections on the skin, nails
or head, molluscum contagiosum infection). There are
also infections that often happen to children with HIV
but also attack children without HIV. The infections
include chronic otitis media and persistent diarrhea.
Infections were made worse by lack of nutrition or
malnutrition that causes progressive weight loss or
failure to thrive in children.
HIV-associated infections in children are jiroveci
pneumocystis pneumonia, esophageal candidosis,
extrapulmonary cryptococcosis and invasive
salmonella infection. 7,10
The clinical manifestations of HIV-AIDS are highly
correlated with the viral load and CD4 count.
Viral load reflects the rate of HIV replication, the
progressivity of the disease, and the risk of death. On
the other hand, the level of CD4 decrease reflects the
level of HIV-induced damage of the body’s immune
system. The higher the viral load and the lower the
CD4, the more clinical manifestations, opportunistic
infections and complications that appears. If the viral
load is low and the CD4 count is high, then the clinical
manifestations will be better.10
The first diagnoses when the patient first admitted
were right pneumothorax and left lobular pneumonia.
The lung infection shows that opportunistic
infection(s) has happened to the patient, and it
happened very quickly, in the first two months of life.
It was caused by heavy immune suppresion, marked
by the very low level of CD4, which is 36 cell/µl (0%),
and the high viral load (1,15 x 106 copy/ml). The
extremely heavy immune supression causes more
clinical manifestations, opportunistic infections and
complications that appear in this patient.
The patient’s routine hematology, urine, and feces
tests results do not show any abnormalities but
signs of hypoxemia were found in the blood gas
analysis, which was treated by nasally administered
oxygen. WSD application was planned to treat the
main cause of hypoxemia in this patient, which is
pneumothorax.
Pneumocystic pneumonia in this patient could
not be proved because no lab examinations were
done to determine the exact cause of pneumonia.
The administration of wide spectrum antibiotics for
this patient without waiting for culture results is a
very correct decision, because infection is a cause
of great morbidity for HIV patients with extremely
heavy
immune
suppression.
Cotrimoxazole
administration is very important for HIV-positive
children (whether there is a certain infection or not)
because it could decrease mortality and incidence
of heavy pneumonia-causing jiroveci pneumocystic
pneumonia infection.
WHO suggests that all children aged four to six
weeks that are born from HIV-infected mothers be
given cotrimoxazole prophylaxis. Children that show
clinical symptoms of HIV-infection must also be give
cotrimoxazole prophylaxis, regardless of their age.
If ARV therapy could not be given to HIV infected
children, then cotrimoxazole is given. If ARV therapy
has been given then cotrimoxazole can only be
stopped when the immune system does not show
any change for six months or more. The duration of
cotrimoxazole administration in children is different.
Cotrimoxazole is given to children suspected of HIVinfection until it can be made certain the children
do not have HIV. Breastfeeding for the child is also
stopped.10
The opportunistic infection in this patient was treated
successfully with WSD application and combination
of cephalosporin (meropenem) and cotrimoxazole.
It turns out that the medical combination shows
adequate response, which can be seen from the
clinical improvement after 20 days in the hospital.
In this patient, diagnosis was confirmed based on the
mother’s history of HIV infection, the opportunistic
infection that occur, chest x-ray result, positive HIV
RNA test result, high viral load, and low CD4 level.
Viral test result could determine if the baby was
infected in the first month of his life, and a positive
result regardless of age is deemed enough to confirm
the diagnosis of HIV infection. Ideally, virological
examination must be done to two samples taken
at two different times. It is important for confirming
and assuring the exact diagnosis. It is not done in this
patient because of financial problems.
Since an infection began, at least 10 billion viruses is
formed every day, but most of them will die because
of the very short half-life. Therefore, even though the
replication happens so fast, the patient will still be
healthy without ARV, as long as the immune system
is still functioning well. The most effective way to
suppress HIV replication continuously is to start
treatment with an effective ARV combination.
263
In patients with a CD4 T-cells count of more
than 200/µl, opportunistic infections that often
happen are pneumonia, tuberculosis, herpes
zoster, oropharyngeal candidiasis, onycomycosis
and gingivitis. If the CD4 T-cell count are less than
200/µl, infections that often happen are jiroveci
pneumocystis, coccydiomycosis, and miliary and
extrapulmonary TBC . If the CD4 T-cell count is less
than 100/µl, infections that often happen are herpes
simplex, toxoplasmosis, cryptococcosis, esophageal
candidiasis. While if the CD4 T-cells count is under
50/µl, cytomegalovirus and mycobacterium avium
complex infections happen.
To prevent the resistance from emerging, ARV
must be used continuously with a very high level
of compliance. The involvement of the patient with
the family, spouse, or friends is very important in all
considerations and decisions to start ARV.13
Because of the patient’s opportunistic infection with
a positive HIV RNA, a CD4 level of 36 cells/µl (0%)
and a high viral load, then the patient should receive
ARV therapy that could suppress viral replication—in
accordance with WHO recommendation. However,
because of the family’s social economic condition
(deceased mother; patient nursed by grandparents;
father’s low income), it is feared that ARV therapy in
this patient is not continuous. For the time being ARV
264
therapy in this patient is postponed and cotrimoxazole
prophylaxis is given, while family counseling is done.
However, the patient never appears for control. Four
months later, he died.
As the conclusion, an HIV-AIDS case was reported in
a two-month-old baby from an HIV-infected mother.
The risk of HIV transmission in this patient is possibly
gained during pregnancy and the labor process.
Diagnosis was confirmed on the basis on medical
history, clinical manifestations, and virological
examinations. In this patient, IO has been treated
well but ARV was never given because of the family
condition.
Stevent Sumantri1
Zubairi Djoerban2
1
HIV/AIDS Medical Observer and Activist, Department of Internal Medicine,
Jakarta.
2
Department of Internal Medicine, Faculty of Medicine, University of Indonesia,
Acta Med Indones. 2008 July;40(3):117-23
265
Clinical Manifestations and Antiretroviral
Management of HIV/AIDS Patients with
Tuberculosis Co-infection in Kramat 128 Hospital
Abstract
Aim: to give a description of HIV-AIDS and tuberculosis co-infection in Jakarta, viewed from the perspective of virologic and immunologic
status and the correct selection of antiretrovirals.
Methods: cross-sectional descriptive study was performed on the outpatient clinic of ‘Kramat 128, from June to July 2007. Tuberculosis
infection was confirmed chest Xray or sputum acid fast smear Kral load was determined by Polymerase Chain Reaction (PCR) and CD4 count
done by flow cytometry. The data were then analyzed using SPSS 14`’ and Chi Square tests for proportional data.
Results: the study enrolled 130 patients with the prevalence of tuberculosis co-infection of 66.9% (n=87). The TB co-infected patients came
with more clinical manifestations (3-4 manifestations) than the non co-infected ones (2-3 manifestations; p<0.001). They also underwent
more hospitalizations (44.8% vs. 11.6%,p=0.003), had lower CD4 levels (126.49 cell/pL vs. 240.68 cell/p.L; p=0.001) and more patients
with CD4 levels of below 100 cell/pL (64.6% vs. 25.6%; p<O.001). The co-infected patients had more virologic failure than the non coinfected ones (38% vs. 12.5%; p=0.030), and so did the co-infected patients treated with nevi rapine than those treated with efavirenz
(37.8% vs. 6.3%; p=0.019).
Conclusion: tuberculosis co-infection complicated the clinical management of People Living with HIV-AIDS (PL WHA) and the antiretroviral
regimen selection in these patients need to be modified. Sub-sequent studies were needed to confirm this study result of superior efavirenz
based therapy in the TB co-infected PL WHA.
Key words: HIV/AIDS, tuberculosis co-infection, antiretroviral therapy, efavirenz, nevirapine.
Introduction
HIV/AIDS is an emerging health problem worldwide,
including in Indonesia. The global number of people
living with HIV/AIDS (PLWHA) is estimated to be
more than 39.5 (34.1-47.1) million (WHO/UNAIDS
estimation, 2006).’ The exact data on number of
PLWHA in Indonesia still vary according to the source,
but it is predicted that the prevalence will keep
increasing. The prevalence varies between 88.600
to 138.800 (Garnett and Grassly, 2002); 100.000 to
290.000 (UNAIDS/WHO, 2006) and 165.000 to 216.000
(Ministry of Health, 2006).2-4
Treatment of HIV/AIDS using antiretroviral
combination therapy was successful in significantly
reducing morbidity and mortality of HIV/AIDS.
However, availability of first-line antiretroviral agent
in Indonesia is still limited, such as Lamivudine
(3TC), Zidovudine (AZT), Stavudine (d4T), Nevirapine
(NVP) and Efavirenz (EFV). This constraint elevates
the essential selection of combination among the
five antiretrovirals, and the selected antiretroviral
regimen should be able to provide higher success
rate.
The HIV/AIDS problem in Indonesia is also marked
by the high prevalence of pulmonary tuberculosis.
Based on the available data, the prevalence ranges
between 162 to 379/100.000 population (WHO, 2005).
Indonesia together with India, Bangladesh, Vietnam,
Cambodia, Thailand, and Myanmar, are enlisted as
the 22 countries with high TB burden. More than 80%
of all TB cases worldwide are from these countries. It
is estimated that TB kills more than 2 million people
each year, 26% of all preventable death in developing
countries.5 Pulmonary TB and HIV/AIDS are two disease
entities that could increase morbidity and mortality
of each other. Besides, combination of antiretroviral
and antituberculosis therapy could also result in
disadvantageous interaction, Antituberculosis, in
this context rifampicin, could decrease serum level
of protease inhibitor (PI) and nonnucleoside reverse
transcriptase inhibitor (NNRTI; antiretroviral agents
up to 90% or even more, leaving less than 10%
serum drug level. On the other hand, P1 group could
increase rifabutin antituberculosis level from two- to
four-fold, which results in clinical toxicity (leukopenia,
uveitis, arthralgia, and skin discoloration). 6-9
267
Clinical Manifestations and Antiretroviral
Management of HIV/AIDS Patients with
Tuberculosis Co-infection in Kramat 128 Hospital
The aim of this study is to provide initial illustration
on HIV/AIDS and tuberculosis coinfection in Jakarta
especially in Kramat 128 Hospital, based on the
immunological and virological status point of view,
and proper choice of antiretroviral agents.
Methods
This is a cross-sectional descriptive study performed
at the Kramat 128 Hospital Jakarta Outpatient Clinic
throughout June and July 2007. Data were collected
through direct interview and medical record tracing.
The inclusion criteria are patients willing to be
interviewed and considered elligible to answer
questions. Exclusion criteria include patients with
incomplete or lost medical record. Sampling method
of subjects was consecutive sampling, i.e. all HIVAIDS + TB patients admitted during the above period
are included as study subjects.
Confirmation of TB infection in the lungs was done
through combination of clinical manifestations and
chest X-ray, and acid-fast staining when performed.
Viral Load was measured using Polymerase Chain
Reaction (PCR) method in referral laboratories at
Dharmais Hospital or Cipto Mangunkusumo Hospital.
Measurement of CD4 level was also performed by
the referral laboratories at both hospitals using flow
cytometry. Virologic failure is defined as detection of
viral load that persists after 6month ARV therapy.
After a patient is diagnosed HIV-positive and fulfilled
the therapeutic criteria, i, e. AIDS (HIV positive with
opportunistic infection), CD4 <350 cells/µL or Viral
Load >55.000 copies, the patient begins to receive
antiretroviral (ARV) therapy. The first choice or ARV
is based on the patient’s clinical status, patient
usually receive combination of 3TC+AZT+NVP as
the first regimen. Patients with anemia receive d4T
as a replacement for AZT, HCV-positive patients
are considered to receive EFV instead of NVP, and
pregnant patients do not receive EFV as a part of their
RV regimen. The 3TC dose is 2 x 150 mg with brand
name Hiviral or Duviral (in combination with AZT 300
g). Dosage for AZT is 2 x 300 mg with brand name
Duviral (in combination with 3TC 150 mg). Dosage for
d, T is 2 x 30 mg with brand name Stavir. Dosage for
Nevirapin is 2 x 200 mg with brand name Neviral, and
for Efavirenz is I x 600 mg with brand name Stocrin,
Efavir and Aviranz.
In patients with TB coinfection, treatment should be
268
started with antituberculous drugs according to DOTS
regimen before initiation of ARV Antituberculous
drugs should be given during the first two weeks,
then followed by simultaneous ARV administration.
Data were then collected and tabulated using
SPSS program version 14. Statistical analysis was
also performed with the said program using nonparametric test, i.e. Chi Square, that was chosen due
to abnormal data distribution of proportional data.
Results
There were 130 patients who participated in this
study, and the gender distribution was 26 females
(20%) and 104 males (80%). In general we found
intravenous drug injection 51.5% (n=67) and sexual
intercourse 46.9% (n=61) as the main factors for
transmission in these patients. Transmission in female
was mainly through sexual intercourse (88.5%), while
in male through intravenous drug injection (61.5%).
The mean age of patients in this study was 32.30
years, the youngest patient was 22 years old and
the oldest 56 years old. In patients younger than 30
years of age (n=69/130), the most common way of
transmission was through intravenous drug injection
(72.5%). On the other hand, the most common way
of transmission in patients above 30 years of age
(n=61/130) was through sexual intercourse (70.7%).
The most common opportunistic infection found in
this study was pulmonary TB 66.9% (87/130), followed
by oral candidosis 36.9% (48/130), Toxoplasma
encephalitis 16.2% (21/130) and recurrent pneumonia
10.8% (14/130). As for the incidence of toxoplasma
patients found elevated ALT and AST level to more
than twice normal value in 21 subjects (67.7%) for AST
and 12 subjects (38.7%) for ALT, with mean increase of
42.9 points for AST and 26.5 points for ALT.
The most common clinical manifestation in this
study was weight loss (76.9%), cough that lasted
for at least one month (76.2%), prolonged fever
(58.5%), chronic diarrhea (43.8%), aphthae and
pain in swallowing (43.1%), and dyspnea (36.9%).
Patients with pulmonary TB co-infection presented
with more severe clinical manifestations compared
to patients without co-infection. (Table 2) Patients
with TB co-infection usually present with 3 to 4
clinical manifestations (mean=3.8; 95% CI 3.52-4.09)
compared to patients without co-infection, i.e. 2 to
3 clinical manifestations (mean=2.74; 95% CI 2.353.14; p<0.001). Patients with pulmonary TB also need
more frequent hospitalization compared to patients
without pulmonary TB: 44.8% vs. 11.6% (39/87 vs 5/43,
p=0.003). Patients with TB co-infection, considering
that they have more clinical manifestations and
need for hospitalization, seemed to show worse
general condition compared to patients without coinfection.
In this study patients were admitted with mean
CD4 level 156.39 cells/µL. The other 66.2% (86/118)
presented with serum CD4 level below 200 cells/
µL. (low), 13.1% (17/118) between 200-350 cells/µL
and 11.5% (15/118) above 350 cells/µL (high). Mean
elevation of CD4 after 6-month ARV therapy was
132.70 cells/µL. Mean elevation of CD4 in patients
with virologic failure (VL still detected) showed lower
score compared to successful patients, 82.3 cells/uL
vs. 156.7 cells/uL (95% CI 24.9-139.7 vs. 116.7-196.7;
p=0.005). Choice of ARV also contributes to the
elevation of CD4 level, and choosing AZT + 3TC +
EFV showed mean elevation of CD4 level 215.5 cells/
uL (95% CI 124.3-306.7), d4T + 3TC +NVP showed
146.4 cells/uL (95% CI 80.7-212.1) and AZT+3TC+NVP
showed 134.2 cells/uL (95% CI 101.5-166.9). Choosing
d4T + 3TC + NVP as ARV regimen seemed to result
in the lowest elevation of CD4 level after 6-month
therapy, with mean 62.00 cells/µL (95% CI -308.0237.2; p=0.045).
The choice of ARV regimen in this study was a
combination of 3 from 5 ARV: 3TC, AZT, d4T, NVP, and
EFV. Distribution of regimen choice was as follows:
56.2% 3TC+AZT+NVP (73/123),13.1% 3TC+AZT+ EFV
(17/123), 11.5% 3TC + d4T + EFV (15/123), and 10.8%
3TC + d4T + NVP (14/123). Duration of therapy was
between 1 to 80 months, with mean 20.5 months.
Temporary drug withdrawal was found in 7 patients
and ranged between 1 to 25 months with mean 10.8
months. Therapeutic success that shows undetected
viral load was found in 67.7% (44/65) of patients,
while therapeutic failure was found in 37.7% (21/65)
of patients.
Patients with pulmonary TB presented with lower
mean CD4 level compared to patients without
pulmonary TB, 126.49 cells/µL vs. 240.68 cells/pL
(95% C1 90.20-162.79 vs. 171.66 vs. 309.69; p=0.001).
Patients with pulmonary TB also presented with lower
CD4 count, 64.6% (51/79) of patients with pulmonary
TB presented with CD4 <100 cells/µL compared to
only 21.6% (10/39) patients without pulmonary TB
(p<0.00 1). After 6 month ARV therapy, the mean CD4
cell count in patients with pulmonary TB is also lower
compared to patients without pulmonary TB: 257.13
cells/µL vs. 394.04 cells/µL (95% CI 206.07-308.19 vs.
280.345 (7.34; p=0.015), with the mean elevation
128.58 cells/µL vs. 138.04 cells/µL.
Therapeutic success in patients with 3TC + d4T + EFV
regimen was up to 83.3% (5/6), with 3TC + AZT + EFV
was up to 80% (8/10), with 3TC + AZT + NVP up to
71.7% (38/53) and with 3TC + d4T + NVP regimen
reached 60% (3/5), none of them showed significant
difference with p=0.632.
Anemia after antiretroviral therapy was found in
41.5% (51/123) of patients, with the lowest Hb level
3.5 g/dL and the highest 12.8 g/dL, and mean Hb level
9.95 g/dL (95% CI 9.25-10.64). Liver function test in 31
269
encephalitis, the diagnostic criteria being used in this
study were by CT scan, thus the prevalence could not
be exactly measured because some of the patients
could not afford the cost of examination.
Patients with pulmonary TB also demonstrated
higher virologic failure, 38% (19/50) of patients
with pulmonary TB showed positive viral load after
6-month therapy compared to 12.5% (3/24) in patients
without pulmonary TB (p=0.030). Therapeutic failure
in these patients with TB is thought to be caused
by administration of NVP-based regimen together
with antituberculous drugs. In this case, TB patients
treated with NVP-based ARV regimen demonstrated
higher therapeutic failure ccmpared to EFV based
ARV regimen, i.e. 37.8% vs. 6.3% (14/37 vs. 1/16,
p=0.019).
Discussion
Distribution of HIV/AIDS between male (80%) and
female (20%) patients in this study is similar to the
epidemiological data issued by WHO in 2006, i.e.
82% in male and 18% in female.’ These data shows
increasing percentage of women infected with HIV/
AIDS in the last few years compared to the 1980s
when HIV/AIDS is still dominated by the homosexuals
(74.5%) and male intravenous drug users (14.2%).
The increased percentage in female patients might
be caused by increased number of female IDUs,
and unprotected sexual activity with HIV positive
patients.
Risk factors for HIV/AIDS transmission in Indonesia are
mainly needle injection and sexual intercourse. Our
study data showed 51.5% from needle transmission
and 46.9% from sexual intercourse. This is similar to
the data issued by WHO on 2006, which predicted
51.27% of infection transmitted through intravenous
drug injection and 48.12% from sexual intercourse.
From this study we found that male subjects below
30 years of age which was also an intravenous drug
270
user have a high risk for HIV/AIDS, although the
extent of risk still have to be further studied. However
in male subjects over 30 years old, the most common
way of transmission was through unprotected sexual
intercourse (70.7%, p<0.001). This tendency indicates
the need of counseling and testing (VCT) for the two
groups mentioned above, so that recommendations
for HIV screening in the two groups could be
established.2,3
In our study data TB seems to be the most common
opportunistic infection, which affected around
66.9% of patients. Several studies on prevalence of
HIV/AIDS in patients with TB in Asian countries show
considerably high prevalence. Studies in Asia found
prevalence between 9.4-40%, New Delhi (India)
9.4%, Mumbai (India) 30%, and North Thailand
40%. In Indonesia, to the author’s knowledge, there
is currently no definite prevalence of HIV/AIDS in
patients with TB. Proposed data by Corbett et al. in
2003 estimated the prevalence of co-infection around
0.2% from overall TB cases in Indonesia. However,
these data should be carefully interpreted, because
HIV/AIDS serology screening in TB patients has not
been established as a policy in Indonesia. 10-14
Patients with TB were also the main emphasis in this
study due to the high incidence of TB infection in our
study population (66.9%), and also due to the extent
of problem associated with TB co-infection. Patients
with TB co-infection presented with worse general
condition compared to patients without co-infection.
This could be observed from the higher number
of clinical manifestations (mean 3.8 vs. mean 2.74;
p<0.001) and higher possibility of hospitalization
(44.8% vs. 11.6%; p=0.003) compared to patients
without TB. This result is similar to a number of
previous studies that relate clinical progression of
HIV/AIDS with TB. A study in India revealed that the
chance of clinical TB in patients with HIV(±) after
exposure was 5-10% annually, compared to 5-10%
for a lifetime in patients without HIV infection. 13.14 The
higher prevalence of TB in HIV/AIDS patients is due
to the similarity in the pathogenesis of Cell-Mediated
Immunity, especially the CD4 cell. Suppression of
CD4 cell by HIV will compromise the mechanism
that controls M. tuberculosis infection, which results
in easier invasion and dissemination of disease.
This similarity of pathogenesis also complicates
the TB course, because CD4 suppression lowers the
incidence of caseous necrosis essential to expose
M. tuberculosis to the outside environment. This
Tuberculosis also has a large impact on HIV /
AIDS, approximately 40% of mortality in HIV/AIDS
worldwide is due to TB, with four-fold mortality rate
compared to HIV/AIDS patients without TB. Degree
of immune system destruction in HIV/AIDS patients
is closely related to mortality. Tuberculosis further
suppresses the low CD4 level, causing increased
mortality. A study by Schluger in 2001 shows that for
every predetermined CD4 level, patients with HIV/
AIDS-TB co-infection demonstrate higher mortality
compared to the ones without co-infection. The
above data show that TB and HIV/AIDS co-infection
is a problem that necessitates comprehensive
management. 11-23
This study, which was commenced in Jakarta,
showed that patients with pulmonary TB coinfection presented with lower immunological status
on admission, with mean CD4 level 126.49 cells/µL
and 64.6% of patients with TB co-infection presented
with CD4 level below 100 cells/gL. Patients with TBHIV/AIDS co-infection who required ARV also had
lower CD4 increase (128.58 cells/µL vs.138.04 cells/
µL) with higher therapeutic failure (38% vs 12.5%)
compared to patients without co-infection. TB could
accelerate the course of HIV disease through several
mechanisms, such as cellular activation mechanism
which at the end will increase HIV viral load. TB onset
in HIV/AIDS patients could elevate plasma vir’ mia
level between 5 to 160 times tSchluger, 2001 ).13.23
Higher therapeutic failure in patients with TB-HIV/
AIDS co-infection, 38% vs. 12.5% (p=0.030), is a serious
problem. Patients with TB-HIV/AIDS co-infection are
faced with a complicated drug interaction problem.
Rifampicin as a standard regimen for TB management
in Indonesia has a strong interaction with NNRTI (NVP
and EFV) and P1 group. Indonesia itself still relies on
NNRTI group as the first line for antiretroviral therapy,
while the availability of PI group is still limited and
being used as second-line therapy. Rifampicin induces
cytochrome P450-3A, which results in enhanced
metabolism to PI and NNRTI group, thus reducing the
serum drug level up to 90% or above. However, a study
in Bangkok, Thailand about the efficacy of Nevirapine
and Rifampicin when administrated together, found
that addition of Rifampicin to Nevirapine regimen
did not seem to demonstrate significant difference
in efficacy. In this Thailand study, after 24-week ARV
therapy, 88% of patients receiving both Rifampicin
and Nevirapine reached viral load lower than 400
copies/mi. This result is also supported by a study in
Spain, with lower success rate 74%.2°.25 In Indonesia,
we also have some limitations in choosing ARV, since
we still have to rely on NVP and EFV (NNRTI group)
as one of the main choices for HIV/AIDS therapy.
Based on the Thailand study and other studies, it
seems that nevirapine could be maintained as the
first-line therapy in HIV/AIDS patients, although its
administration should be monitored through routine
liver function test and viral load test to evaluate the
therapeutic success.
In this study 67% of patients received NVP-based
regimen as the first-line therapy, and 24.6% received
EFV as a basis. This study demonstrates that the
therapeutic failure in TB-HIV patients receiving
NVPbased regimen was 38%, compared to only
6.3% (p=0.019) in patients receiving EFV. The result is
similar to a study by Nachega et al in southern part of
Africa, where virologic failure could be minimized to
0% in patients receiving EFV compared to 69% with
NVP. Nachega stated that one of the possible causes
is interaction between NVP and rifampicin commonly
used for tuberculosis therapy in their population.
However, considering that different situations in each
country will result in different therapeutic success
with NNRTI group
and Rifampicin, further study is still needed based
on a e result of current study showing EFV superior
to NVP when being used together with Rifampicin.
Further randomized clinical trial study is expected to
be able to provide clear illustration on EFV, NVP, and
Rifampicin interaction in HIV/AIDS-TB co-infected
patients in Indonesia.7-9,26
Rifabutin, an example of rivamisin group, is the best
hoice in the management of patient with TB-HIV
o-infection. This happens because rifabutin results in
weaker induction of CYP3A, compared with rifampin
rifampicin) that is currently available in Indonesia.
Thus low ARV level could be managed by adjusting
the ARV dose. By increasing available rifabutin and
ARV dosage, we could obtain similar therapeutic
efficacy and suppression of relapse episodes
compared to rifampin (rifampicin). Based on the
above analysis, rifabutin should be considered as a
271
low exposure causes difficulties in establishing TB
diagnosis using acid-fastt staining, and will further
complicate TB diagnosis in HIV/AIDS patients.17-20
therapy for patients with HIV/ IDS-TB co-infection. As
an alternative, although with higher risk of adverse
Patients with pulmonary TB also demonstrated
higher virologic failure, 38% (19/50) of patients
with pulmonary TB showed positive viral load after
6-month therapy compared to 12.5% (3/24) in patients
without pulmonary TB (p=0.030). Therapeutic failure
in these patients with TB is thought to be caused
by administration of NVP-based regimen together
with antituberculous drugs. In this case, TB patients
treated with NVP-based ARV regimen demonstrated
higher therapeutic failure ccmpared to EFV based
ARV regimen, i.e. 37.8% vs. 6.3% (14/37 vs. 1/16,
p=0.019).
Discussion
Distribution of HIV/AIDS between male (80%) and
female (20%) patients in this study is similar to the
epidemiological data issued by WHO in 2006, i.e.
82% in male and 18% in female. These data shows
increasing percentage of women infected with HIV/
AIDS in the last few years compared to the 1980s
when HIV/AIDS is still dominated by the homosexuals
(74.5%) and male intravenous drug users (14.2%).
The increased percentage in female patients might
be caused by increased number of female IDUs,
and unprotected sexual activity with HIV positive
patients.
Risk factors for HIV/AIDS transmission in Indonesia are
mainly needle injection and sexual intercourse. Our
study data showed 51.5% from needle transmission
and 46.9% from sexual intercourse. This is similar to
the data issued by WHO on 2006, which predicted
51.27% of infection transmitted through intravenous
drug injection and 48.12% from sexual intercourse.
From this study we found that male subjects below
30 years of age which was also an intravenous drug
user have a high risk for HIV/AIDS, although the
extent of risk still have to be further studied. However
in male subjects over 30 years old, the most common
way of transmission was through unprotected sexual
intercourse (70.7%, p<0.001). This tendency indicates
the need of counseling and testing (VCT) for the two
groups mentioned above, so that recommendations
for HIV screening in the two groups could be
established.2,3
In our study data TB seems to be the most common
opportunistic infection, which affected around
66.9% of patients. Several studies on prevalence of
272
HIV/AIDS in patients with TB in Asian countries show
considerably high prevalence. Studies in Asia found
prevalence between 9.4-40%, New Delhi (India)
9.4%, Mumbai (India) 30%, and North Thailand
40%. In Indonesia, to the author’s knowledge, there
is currently no definite prevalence of HIV/AIDS in
patients with TB. Proposed data by Corbett et al. in
2003 estimated the prevalence of co-infection around
0.2% from overall TB cases in Indonesia. However,
these data should be carefully interpreted, because
HIV/AIDS serology screening in TB patients has not
been established as a policy in Indonesia. 10-14
Patients with TB were also the main emphasis in this
study due to the high incidence of TB infection in our
study population (66.9%), and also due to the extent
of problem associated with TB co-infection. Patients
with TB co-infection presented with worse general
condition compared to patients without co-infection.
This could be observed from the higher number
of clinical manifestations (mean 3.8 vs. mean 2.74;
p<0.001) and higher possibility of hospitalization
(44.8% vs. 11.6%; p=0.003) compared to patients
without TB. This result is similar to a number of
previous studies that relate clinical progression of
HIV/AIDS with TB. A study in India revealed that the
chance of clinical TB in patients with HIV(±) after
exposure was 5-10% annually, compared to 5-10%
for a lifetime in patients without HIV infection. 13.14 The
higher prevalence of TB in HIV/AIDS patients is due
to the similarity in the pathogenesis of Cell-Mediated
Immunity, especially the CD4 cell. Suppression of
CD4 cell by HIV will compromise the mechanism
that controls M. tuberculosis infection, which results
in easier invasion and dissemination of disease.
This similarity of pathogenesis also complicates
the TB course, because CD4 suppression lowers the
incidence of caseous necrosis essential to expose
M. tuberculosis to the outside environment. This
low exposure causes difficulties in establishing TB
diagnosis using acid-fastt staining, and will further
complicate TB diagnosis in HIV/AIDS patients.17-20
Tuberculosis also has a large impact on HIV /
AIDS, approximately 40% of mortality in HIV/AIDS
worldwide is due to TB, with four-fold mortality rate
compared to HIV/AIDS patients without TB. Degree
of immune system destruction in HIV/AIDS patients
is closely related to mortality. Tuberculosis further
suppresses the low CD4 level, causing increased
mortality. A study by Schluger in 2001 shows that for
This study, which was commenced in Jakarta,
showed that patients with pulmonary TB coinfection presented with lower immunological status
on admission, with mean CD4 level 126.49 cells/µL
and 64.6% of patients with TB co-infection presented
with CD4 level below 100 cells/gL. Patients with TBHIV/AIDS co-infection who required ARV also had
lower CD4 increase (128.58 cells/µL vs.138.04 cells/
µL) with higher therapeutic failure (38% vs 12.5%)
compared to patients without co-infection. TB could
accelerate the course of HIV disease through several
mechanisms, such as cellular activation mechanism
which at the end will increase HIV viral load. TB onset
in HIV/AIDS patients could elevate plasma viremia
level between 5 to 160 times (Schluger, 2001).13.23
Higher therapeutic failure in patients with TB-HIV/
AIDS co-infection, 38% vs. 12.5% (p=0.030), is a serious
problem. Patients with TB-HIV/AIDS co-infection are
faced with a complicated drug interaction problem.
Rifampicin as a standard regimen for TB management
in Indonesia has a strong interaction with NNRTI (NVP
and EFV) and P1 group. Indonesia itself still relies on
NNRTI group as the first line for antiretroviral therapy,
while the availability of PI group is still limited and
being used as second-line therapy. Rifampicin induces
cytochrome P450-3A, which results in enhanced
metabolism to PI and NNRTI group, thus reducing the
serum drug level up to 90% or above. However, a study
in Bangkok, Thailand about the efficacy of Nevirapine
and Rifampicin when administrated together, found
that addition of Rifampicin to Nevirapine regimen
did not seem to demonstrate significant difference
in efficacy. In this Thailand study, after 24-week ARV
therapy, 88% of patients receiving both Rifampicin
and Nevirapine reached viral load lower than 400
copies/mi. This result is also supported by a study in
Spain, with lower success rate 74%.24,25 In Indonesia,
we also have some limitations in choosing ARV, since
we still have to rely on NVP and EFV (NNRTI group)
as one of the main choices for HIV/AIDS therapy.
Based on the Thailand study and other studies, it
seems that nevirapine could be maintained as the
first-line therapy in HIV/AIDS patients, although its
administration should be monitored through routine
liver function test and viral load test to evaluate the
therapeutic success.
In this study 67% of patients received NVP-based
regimen as the first-line therapy, and 24.6% received
EFV as a basis. This study demonstrates that the
therapeutic failure in TB-HIV patients receiving
NVPbased regimen was 38%, compared to only
6.3% (p=0.019) in patients receiving EFV. The result is
similar to a study by Nachega et al in southern part of
Africa, where virologic failure could be minimized to
0% in patients receiving EFV compared to 69% with
NVP. Nachega stated that one of the possible causes
is interaction between NVP and rifampicin commonly
used for tuberculosis therapy in their population.
However, considering that different situations in each
country will result in different therapeutic success
with NNRTI group
and Rifampicin, further study is still needed based
on a e result of current study showing EFV superior
to NVP when being used together with Rifampicin.
Further randomized clinical trial study is expected to
be able to provide clear illustration on EFV, NVP, and
Rifampicin interaction in HIV/AIDS-TB co-infected
patients in Indonesia.7-9,26
Rifabutin, an example of rivamisin group, is the best
hoice in the management of patient with TB-HIV
o-infection. This happens because rifabutin results in
weaker induction of CYP3A, compared with rifampin
rifampicin) that is currently available in Indonesia.
Thus e low ARV level could be managed by adjusting
the RV dose. By increasing available rifabutin and
ARV dosage, we could obtain similar therapeutic
efficacy and suppression of relapse episodes
compared to rifampin (rifampicin). Based on the
above analysis, rifabutin should be considered as a
therapy for patients with HIV/AIDS-TB co-infection.
As an alternative, although with higher risk of
adverse effects with consideration to individual
variability of CYP3A, rifampicin could be used with
Efavirenz-based ARV regimen. The increasing dose of
EFV in this context up to 800 mg/day to compensate
for increased drug metabolism by CYP3A enzyme,
as commended by some other studies, does not
seem to the necessary. Standard-dose Efavirenz, i.e.
600 mg/day, is still effective in the management of
patients with HIV/AIDS-TB co-infection in Jakarta.
This recommendation is in line with our study, where
273
every predetermined CD4 level, patients with HIV/
AIDS-TB co-infection demonstrate higher mortality
compared to the ones without co-infection. The
above data show that TB and HIV/AIDS co-infection
is a problem that necessitates comprehensive
management. 11-23
patients with EFV demonstrate higher therapeutic
success up to 93.8%, spared to only 62.2% (p=0.019)
in patients with NVP. 7-9,27,28
Conclusion
We can conclude from this study that TB is an
opportunistic infection often found in HIV/AIDS
patients in Jakarta. Tuberculosis co-infection in these
patients result in more severe clinical manifestation
and higher possibility of hospitalization. Patients with
TB co-infection also present with more complicated
problem during management of their immunological
and virological status. Therapeutic failure in this
group of patients, both virological failure and failure
to improve their immunological status, complicates
the management o these patients. Choice of ARV in
this group of patients is also faced with possibilities
of therapeutic failure using combination of NVP
and Rifampicin. Solution for this problem could be
through administration of EFV-based regimen 600
mg daily. Nevirapine could still be used for first-line
therapy as long as it is routinely monitored.
References
1.
AIDS epidemic update. Joint united nations programme on HIV/
AIDS. Geneva: UNAIDS and World Health Organization; 2006. p.
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Grassly NC, Garnett GP. The future 4of the HIV pandemic. Bulletin
of the World Health Organization. 2005;83:378-83.
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AIDS epidemic update. Joint United Nations Programme on HIV/
AIDS. Geneva: UNAIDS and World Health Organization; 2006. p.
40-2.
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Ministry of Health of Indonesia. Estimate of the people living with
HIV/AIDS. Released on December 1, Jakarta. 2006.
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WHO Report 2003. Global tuberculosis control. Surveillance,
planning, financing. http://www.who.int/gtb/publications/
globrep02/index.html. WHO/CDSITBI2002.245.
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Ministry of Health of Indonesia. National TB prevalence survey.
Jakarta; 2004.
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Burman WJ, Jones BE. Treatment of HIV-related tuberculosis in
the era of effective antiretroviral therapy. Am J Respir Crit Care
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Burman WJ, Qallicano K, Peloquin C. Therapeutic implications of
drug interactions in the treatment of HIVrelated tuberculosis. Clin
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Sun E, Heath-Chiozzi M, Cameron DW, Hsu A, Granneman RG,
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(abstract MoB171).
10. Sharrna SK, Aggarwal G, Seth P, Saha PK. Increasing HIV
seropositivity among adult tuberculosis patients in Delhi. Indian
J Med Res. 2003;117:239-42.
11. Mohanty KC, Basheer PMM. Changing trend of HIV infection and
tuberculosis in a Bombay area since 1988. Indian J Tuberc. 1995;
42:117-20.
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12. Yanai H, Uthaivarovit W, Panich V, Sawanpanyalert P, Chaimanee
B, Akarasewi P, et al. Rapid increase in HIV related tuberculosis,
Chiang Rai, Thailand 1990-1994. AIDS. 1996;10:527-31.
13. Schluger NW, Burzynsk: J. Tuberculosis and HIV infection:
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2001;2(4):356-65.
14. Murray JF. Tuberculosis and HIV infection: A global perspective.
Respiration. 1998;65:335-.42.
15. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the
risk of tuberculosis among intravenous drug users with human
immunodeficiency virus infection. N Engl J Med. 1989;320(9):545-50.
16. Glynn JR. Resurgence of tuberculosis and the impact of HIV
infection. Br Med Bull. 1998;54:579-93.
17. Kanaya AM, Glidden D, et.al. Identifying pulmonary tuberculosis
in patients with negative sputum smear results. Chest.
2001;120:349-55.
18. Severe P, Leger P, et.al. Antiretroviral therapy in a thousand
patients with HIV/AIDS in Haiti. N Engl J Med. 2005;353; 22:232534.
19. Wannamethee SG, Sirivichayakul S, et.al. Clinical and
immunological features of human immunodeficiency virus
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20. Condos R, Rom WN, Liu YM, Schluger NW. Local immune responses
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21. Pape JW, Jean SS, Ho JL, Hafner A, Johnson WD Jr. Effect of
isoniazid prophylaxis on incidence of active tuberculosis and
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22. Whalen C, Horsburgh CR, Horn D, Lahart C, Simberkoff M, - Ellner
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Klein RS, Munsiff SS, Ortona L, Cauda R, Fauci AS. Effect of
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24. Manosuthi W et al. Comparison of plasma levels of nevirapine,
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HIV - I infected patients receiving and not receiving rifampicin:
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Nevirapine in HIV infected patients with tuberculosis. AIDS. 2003;
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28. Lopez-Cortes LF, Ruiz R, Viciana P, Alarcon A, Leon E, Sarasa M,
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Opportunistic Infections. Chicago: 2001. p.52.
AIDS: From Basic Knowledge
to HIV-TB Co-Infection
Zubairi Djoerban1
1
Acta Med Indones. 2008 Jul;40(3):113
275
Abstracthas become a serious problem in
HIV/AIDS
Indonesia. It has been estimated that there were
110,800 people living with HIV in Indonesia in
2002 and by 2006, the figure increased to more
than 190,000 people.
The most common mode of HIV transmission
in Indonesia is by sharing needles for injecting
drugs, followed by sexual transmission and
infected mother passing the virus to her child.
Transmission through sharing needles is common
in big cities as well as the prison populations. The
prevalence of HIV infection in inmates of some
prisons are very high, that is more than 30%.
Lack of knowledge about HIV/AIDS has made
prevention efforts difficult. In our current edition
of Acta Medica Indonesians (The Indonesian
Journal of Internal Medicine), Herke G Sigarlaki
reported his research in 2006 about the knowledge
among inmates of prison at Singkawang, West
Borneo. It is very pitiful that 48.33% respondents
stated that HIV transmission among drug users is
mainly through smokers and alcoholic drinkers or
the risk factor of drug abuse includes living with
a family member who had taken up smoking and
alcoholic consumption. This finding is important
because how the community could prevent the
HIV infection if they did not know the exact
mode of transmission. We have known that HIV
transmission among drug users is caused by
sharing needles, lending their needles without
being sterilized first.
There are 13,000 people living with HIV/AIDS
who have received free-ARV treatment, an
antiretroviral drugs or AIDS drugs, all over
Indonesia. The Service Center for HIV/AIDS at
Cipto Mangunkusumo Hospital has been treating
more than 3.000 people since early January
2008. It has also been treating more than 2,000
people at Dharmais Cancer Hospital and more
than 1,000 people living with AIDS have received
the ARV treatment. Approximately 50% of those
patients with AIDS also had tuberculosis, either
lung tuberculosis or lymph node tuberculosis and
other extra-pulmonary tuberculosis. The problem
of concomitant disease of tuberculosis to HIV
infection has become very important issue since
there are different treatments and prognoses.
Stevent and Zubairi Djoerban reported the
management of HIV infection in patients with
HIV/AIDS who also had tuberculosis.
Currently, doctors who provide treatment for HIV/
AIDS include specialists, consultants, and general
practitioners. The specialists are from various
disciplines such as internal medicine, pediatrics,
obstetrics, psychiatris, pulmonology, etc. The
consultants are also from various fields such as
internists who also have consultant degree in
hematology and medical oncology, pulmonology,
allergy-immunology, tropical infection, and
pediatricians who also have degree in consultant
of allergy-immunology. Education is necessary in
establishing the doctors’ competence to manage
HIV/ AIDS treatment, including education
throughout undergraduate study, specialist
study or the study of specialist consultant as
well as continuous medical education after
graduation. Therefore, it should be regulated by
every collegium. Moreover, a continuous medical
education called “Continuing Professional
Development” should be carried out for doctors
who have completed their formal education
so that people living with HIV/AIDS could have
optimal treatment, including those who also have
tuberculosis.
277
AIDS: From Basic Knowledge
to HIV-TB Co-Infection
Simple Methods on Supporting ARV
Therapy Services
Samsuridjal Djauzi1
1
Jakarta.
Acta Med Indones. 2008 Apr;40(2):53-4
279
Early antiretroviral (ARV) therapy by using
zidovudine
Abstract(AZT) has been initiated in Indonesia
since 1987, followed by duotherapy, i.e. combining
the AZT and lamivudine (3TC). Either monotherapy
or duotherapy treatments to resistance against ARV.
In 1996, tripledrug therapy was identified effective
in HIV management. Combination of three or more
antiretroviral therapy is better either on clinical,
immunological, virology, or epidemiology aspects.
Clinically, the mortality rate and hospitalization
rate can be significantly decreased. In Jakarta,
Mahdi found that there was a drastic decrease of
mortality rate 3 months following ARV treatment
of HIV infected patients. Although the mortality
number was still high in the first three month, i.e.
approximately 30%.3 It extremely decreased when
the patient survived. The mortality in the first three
months was mostly caused by severe opportunistic
infections which occurred before ARV treatment
was commenced. Most HIV cases were diagnosed at
late stage with low CD4+ lymphocyte counts, which
became the most difficult problem.
Yunihastuti in 2005 reported that 42.6% of treated
HIV/AIDS cases in RSCM have less than 50 cells/mL2
of absolute CD4+ count. Mahdi also reported that
the mortality risk of a group with CD4+ count < 50
cells/ mL2 was 3.39 lower than a group of higher
CD4+ count.1
Therefore, an early diagnosis of HIV is required to
decrease the mortality rate of HIV/AIDS cases by
providing affordable and well-distributed services of
Voluntary Testing and Counseling (VCT).
In conducting the ARV therapy, WHO guidelines
recommend CD4+ count as a criteria in initiating and
monitoring improvement of ARV therapy.3 The CD4+
count has been established since 1986 by Djoerban
at Ciptomangunkusumo Hospital. At that time, it
was detected by immunofluoroscent microscope.
Afterward, CD4+ count by a flowcytometer was
lately developed. Using flowcytometer, the count
was easier and more reliable because it was not
interfered by intraobserver subjectivity; thus, it
subsequently became more popular.
Although the CD4+ count by flowcytometry is
easier, it is expensive and only provided in referral
hospital. However, CD4+ count is also expensive,
i.e. it costs about IDR 120,000. Therefore, it is
necessary to find another alternative method,
which is simpler and more reliable to substitute the
CD4+ count, especially to determine the indication
of ARV therapy. A report by Lydia found that in
AIDS cases, the CD4+ count of 200 cells/mL was
more less similar with total lymphocyte of 1100.4
Similar finding was also reported by Suryamin, that
performed a correlation between total lymphocyte
and CD4+ count in HIV-infected patients.5 The WHO
guidelines in 2003 for its program in developing
countries has recommended CD4+ count less than
200 cells//mL or total lymphocyte count less than
1200 to start an initial therapy for asymptomatic
patient.3 However, the correlation is frequently
inaccurate, particularly in monitoring improvement
of the ARV therapy.6-7 In contrast, other studies
still indicate a good correlation of it.8-9 Obviously,
we need another alternative method to improve
specificity and sensitivity of such examination.
Spacek, et al tried to add several standard
examination to improve specificity and sensitivity
of total lymphocyte count as a predictor for CD4+
lymphocyte count, and found that by adding
hemoglobin examination, we may provide higher
sensitivity for total lymphocyte count and may
decrease the false negative result.10 A study in
Indonesia by Wilhan, et al with smaller number
of samples as demonstrated this study, has also
supported the study result by Spacek, et al.11 A study
to evaluate the correlation between total lymphocyte
count or other parameters and CD4+ count should
be conducted with adequate number of sub iects.
Simple methods in providing approximate CD4+
count should be further developed since it will bring
benefit for management of HIV/AIDS in facilitylimited settings.
281
Simple Methods on Supporting ARV
Therapy Services
References
1.
2.
Mahdi HIS, Djauzi S, Sukmana N, Oemardi M. One year AIDS
patients survival in Dharmais cancer hospital (retrospective
study analysis). [Thesis]. Jakarta: Department of Internal
Medicine School of MedicineUniversity of Indonesia; 2004.
Yunihastuti E, Wigati, Karjadi TH, Imran D, Rohmi S, Kusbiantoro
H, et al. Spectrum of opportunistic infections among HIVinfected patients in Jakarta. Abstract book Australasian
Society of HIV Medicine Conference. Hobart, October 2005.
3.
World Health Organization. Scaling up antiretroviral therapy
in resource-limited settings: Treatment guidelines for a public
health approach 2003 revision.
4.
Lydia A. Total lymphocyte count as a predictor for CD4+
lymphocyte count among AIDS patient [thesis]. Jakarta:
Department of Internal Medicine School of Medicine
University of Indonesia; 1996.
5.
Suryamin M. Total lymphocyte count as indicator to start
antiretroviral therapy among people living with HIV/AIDS.
[thesis( Jakarta: Department of Internal Medicine School of
Medicine University of Indonesia; 2002.
6.
Gange SJ, Lau B, Phair J, Riddler SA, Detels R, Margolick JB.
Rapid declines in total lymphocyte count and hemoglobin
in HIV infection begin at CD4 lymphocyte counts that justify
antiretroviral therapy. AIDS. 2003;17:119’21.
282
7.
Liotta G, Perno CF, Ceffa S, Gialloreti LE, Coehlo E, Erba F, et
al. Is total lymphocyte count a reliable predictor of the CD4
lymphocyte cell count in resource-limited settings? AIDS
2004; 18:1082-3.
8.
Badri M, Wood R. Usefulness of total lymphocyte count in
monitoring highly active antiretroviral therapy in resource
limited-settings. AIDS 2003; 17:541-5.
9.
Kumarasamy N, Mahajan AP, Flanigan TP, Hemalatha R, Mayer
KH, Carpenter CC, et al. Total lymphocyte count (TLC) is a useful
tool for the timing of opportunistic infection prophylaxis in
India and other resource-constrained countries. J Acquired
Immune Defic Syndr. 2002;31:378-83.
10. Spacek LA, Griswold M, Quinn TC, Moore RD. Total lymphocyte
count and hemoglobin combined in an algorithm to initiate
the use of highly active antiretroviral therapy in resourcelimited settings. AIDS. 2003;17:1311-7.
11. Wilhan, Budiono E. Total lymphocyte count and hemoglobin
combined to predict CD4 lymphocyte counts of less than 200
cells/mm’ in HIV/AIDS. Acta Med Indones. 2008;40(2):58-6
Jacquita S. Affandi1
Patricia Price1,2
Darma Imran3
Evy Yunihastutia
Samsuridjal Djauzi3
Catherine L. Cherry4,5,6
1
School of Surgery and Pathology, University of Western Australia, Perth,
Australia.
2
Clinical Immunology and Immunogenetics, Royal Perth Hospital, Perth,
Australia.
3
Pokdisus (Working Group on AIDS) Faculty of Medicine, University of
Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
4
Burnet Institute, Melbourne, Australia.
5
Infectious Diseases Unit, Alfred Hospital, Melbourne, Australia.
6
Department of Medicine, Monash University, Melbourne, Australia.
AIDS Res Hum Retroviruses. 2008 Oct;24(10):1281-4.
Mary Ann Liebert, Inc.
283
Can We Predict Neuropathy Risk before Stavudine
Prescription in a Resource-Limited Setting?
Abstract
A toxic sensory neuropathy associated with exposure to inexpensive nucleoside analogue reverse transcriptase inhibitors (NRTIs) [particularly
stavudine (d4T)] causes dilemmas in the management of patients with HIV, especially in resource-poor settings. Here patients (n=96) attending
Pokdisus AIDS Clinic at the Cipto Mangunkusumo Hospital, Jakarta who had been treated with d4T were screened for symptomatic neuropathy.
Clinical, demographic, and genetic factors were considered as possible neuropathy risk factors. DNA from saliva was used to examine alleles
of TNFA-308, BAT1 (intron 10), TNFA-1031, IL1A4845, and IL12B (3’UTR). The prevalence of neuropathy (symptoms and signs) was 34%. On
multivariate analysis, neuropathy following d4T exposure was associated with increasing age, increasing height, and TNFA-1031*2 (model
p=0.0009). Isoniazid exposure (present in 56% of patients) was not associated with neuropathy in this cohort, where all patients had received
pyridoxine coadministration. These data suggest that a simple algorithm based on patient age, height, and TNF genotype could be used to
predict the individual’s risk of symptomatic neuropathy prior to prescription of d4T.
Introduction
SENSORY NEUROPATHY (SN) is a common and disabling
complication of HIV disease and some HIV treatments.
Exposure to stavudine (d4T), a potentially neurotoxic
nucleoside analogue reverse transcriptase inhibitor (NRTI),
is an independent risk factor for SN among HIV patients in
Australia and the United States,1,2 and a similar association
is reported from resource-limited settings.3 However, d4T
is an effective antiretroviral agent that is widely available
in relatively inexpensive generic fixed dose combinations.4
It is also associated with a lower risk of severe anemia than
is seen with zidovudine.5 It is therefore likely that d4T use
will remain common in first-line HIV treatment in countries
where access to alternative regimens is limited by cost,
despite high rates of toxicities including SN.
genetic factors associated with risk of neuropathy among
Indonesian HIV patients exposed to d4T.
Material and Methods
This study was undertaken over 5 weeks in August 2006 in
the Pokdisus AIDS Clinic at Cipto Mangunkusumo Hospital,
Jakarta, Indonesia. All adult (age 18 ≥ years) HIV-infected
clinic patients who had ever used d4T were invited to be
screened for neuropathy and give a sample of saliva as
a source of genomic DNA. The study was approved by
the local Human Research and Ethics Committee and all
subjects gave written, informed consent to participate.
Not all patients exposed to d4T develop neuropathy,
suggesting that host factors may play a role in the individual’s
risk. For example, d4T-associated neuropathy is thought
to be caused by the mitochondrial toxicity of this drug
and mitochondrial haplogroup T has been associated with
neuropathy in white patients exposed to NRTIs.6 Genetic
markers of host inflammatory responses may also be an
important determinant of d4T neuropathy risk. Rates and
severity of other complications of HIV and HIV treatments are
associated with cytokine genotype, notably alleles of TNFA.7–9
Further, d4T neuropathy is clinically similar to neuropathy
caused by HIV itself, where disordered inflammation and
altered cytokine levels are well described.10,11
Patients were assessed for neuropathy using the AIDS
Clinical Trials Group Brief Peripheral Neuropathy Screen
(ACTG BPNS).13 Neuropathy was defined as present if the
individual had one or more of the lower limb neuropathic
symptoms elicited using this tool (pain, aching or burning,
pins and needles, or numbness) together with at least one
of the following: absent ankle reflexes or reduced vibration
sense at the great toe (vibration of a 128-Hz tuning fork felt
for 10 s or less). All patients who described neuropathic
symptoms were questioned regarding the timing of
symptom onset relative to stavudine use. Data on possible
laboratory, clinical, and demographic risk factors for
neuropathy were collected from detailed medical records
maintained on all patients attending this clinic. Plasma HIV
viral loads are not routinely performed in this clinic and
were therefore not included in this study.
We have previously documented that demographic
features and host cytokine genotype are associated with
neuropathy risk following d4T (or didanosine) exposure in
Australian whites with HIV.12 Confirmation of these findings
in patients from other ethnic groups would improve our
ability to predict the individual’s risk of SN prior to d4T
prescription, allowing those at highest risk to be prioritized
for access to alternative agents. The aim of the current
study was to determine the clinical, demographic, and
DNA was extracted from saliva using a QIAamp DNA mini
Kit (QIAGEN, USA) and stored at 80°C. Genomic DNA was
screened using established PCR-RFLP assays to determine
the alleles carried at BAT1 (intron 10) (rs9281523), TNFA-308
(rs1800629), and TNFA-1031 (rs1799964).14 Other assays were
based on FAM and VIC-labeled probes and Universal PCR
Master Mix (Taqman, Applied Biosystems) in 5 l reactions.
Assay IDs were C_9546471_10 for IL1A4845 (rs17561) and
C_2084293_10 for IL12B 3<?> UTR (rs3212227).
285
Can We Predict Neuropathy Risk before Stavudine
Prescription in a Resource-Limited Setting?
Statistical analyses were performed using Stata 9.2 (StataCorp, USA). Demographic details of patients with and
without SN were compared using x2 tests (dichotomous
variables), Wilcoxon rank-sum tests [nonnormally
distributed continuous variables, described using median
and interquartile range (IQR)], or unpaired t-tests [normally
distributed continuous variables, described using mean +
standard deviation (SD)]. Associations between genotype
and SN status were assessed individually using x2 tests [with
genotypes grouped as (1,1) versus (1,2 or 2,2) in all analyses
to accommodate small numbers with the (2,2) genotype
at these loci]. Multivariate analyses were undertaken using
multiple case–control logistic regression (including all
factors with p < 0.3 on univariate analyses) with a reverse
selection procedure.
Results
Ninety-six patients participated in this study. Of these, 33
patients (34%) had SN (defined as both symptoms and
signs on the ACTG-BPNS13). Thirty-one of 33 neuropathy
patients stated that their symptoms probably or definitely
began after their first exposure to stavudine. Among the 63
patients classified as “SN free,” a further seven (7%) patients
had neuropathic symptoms but no signs, and 14 (15%)
asymptomatic patients had neuropathic signs.
This cohort was relatively young (mean age 30 years, SD
7 years) and immune deficient at HIV diagnosis (median
CD4 T cell count at diagnosis 40 cells/μl, IQR 17–116 cells/
μl). Most (86%) were male and 54 (56%) had a history of
isoniazid use (all with pyridoxine). Patients had used d4T
for 2–42 (17 ± 9) months.
Univariate analyses of demographic parameters
established that increasing height, female gender, and
hepatitis C seropositivity were associated with SN status.
Weaker associations were evident with age and initial CD4
T cell count (Table 1). On multivariable analysis, height and
age were the only demographic features independently
associated with SN status (model p = 0.005).
Univariate analyses of the genotypes studied showed an
association between TNFA-1031 and SN status (Table 1).
On logistic regression modeling, increasing age and height
combined with TNFA-1031*2 to form the best model of SN
risk (model p = 0.0009) (Table 2).
Discussion
This study found a neuropathy prevalence of 34% among
HIV patients in Jakarta exposed to d4T. The independent
associations with neuropathy in this cohort were increasing
TABLE 1. UNIVARIATE ANALYSES OF DEMOGRAPHIC AND GENETIC FACTORS BY PATIENT SN STATUS
Demographic factors
Height (cm)a
Body mass indexa
Initial CD4 T cells/lμc
Months HIVc
Age (years)a
Female gender
Isoniazid/pyridoxine
Stavudine ever
Zidovudine ever
Lamivudine ever
Efavirenz ever
Nevirapine ever
Protease inhibitor everf
IVDU
HepC+
SN patients
(n = 33)
SN-free patients
(n = 66)
p
170 ± 8..
21.3 ± 2.7
34 (9–98)
20 (14–34)
32 ± 7.6
3%
64%
100%
52%
100%
55%
76%
15%
73%
58%
166 ± 7
20.7 ± 2.9
50 (20–130)
22 (15–32)
29 ± 6.7
19%
52%
100%
54%
98%
41%
81%
13%
67%
48%
0.02b
0.41b
0.2d
0.71d
0.12b
0.03e
0.29e
1.0e
0.82e
0.47e
0.22e
0.55e
0.74e
0.54e
0.03e
10%
7%
48%
7%
74%
8%
9%
27%
21%
63%
0.8e
0.7e
0.04e
0.12e
0.3e
Genetic factorsg
TNFA-308*2
BAT1 (intron10)*2
TNFA-1031*2
IL1A + 4845*2
IL12B(3’ UTR)*2
a
Parametric data: shown as mean ± standard deviation.
b
Unpaired t test (parametric data).
c
Nonparametric data: shown as median (interquartile range).
d
Wilcoxon rank-sum test (nonparametric data).
e 2
x test (dichotomous data).
f
This was lopinavir/ritonavir in all cases, with one patient also having used atazanavir.
g
Shown as percentage of individuals carrying allele 2.
286
p
The prevalence of SN in this cohort was lower than we
have observed in Australian HIV patients using the same
definition,1 despite the fact that all patients in the current
study had used d4T. This may be explained by the relative
youth of the patients studied here, with 6 of 11 (55%)
patients aged at least 40 years having SN, compared with
only 27 of 85 (32%) younger patients. The association
between neuropathy and height is consistent with our
previous description in Australians with HIV, all but one
of whom were male.12 In the current cohort the rate of
neuropathy was 56% in patients taller than 170 cm exposed
to d4T, but only 27% in shorter individuals. Although
isoniazid exposure has been independently associated
with neuropathy risk in other HIV treatment centers3 no
such association was observed here. This may relate to the
universal coadministration of pyridoxine with isoniazid in
this clinic.
Saliva was used in this work as a noninvasive source of
genomic DNA requiring minimal processing prior to DNA
extraction. Sufficient DNA was obtained for the testing
described in all patients, consistent with previous reports
of saliva as a reliable and cost-effective alternative to blood
as a source of genomic DNA.15–17
TABLE 2. MULTIVARIATE ANALYSIS COMPARING
TNFA-1031 GENOTYPE AND DEMOGRAPHIC DETAILS
BETWEEN PATIENTS WITH AND WITHOUT SN YIELDED
A SIGNIFICANT MODELa
Variable
Age (years)
Height (cm)
TNFA-031*2
Odds ratio
1.1
1.1
3.6
95% confidence
interval
1.03–1.18
1.02–1.17
1.3–9.8
We show that easily measured factors influence risk of
neuropathy among patients exposed to d4T. Therefore it is
plausible that a simple algorithm could be used to identify
those patients at highest risk of neuropathy before d4T
prescription, allowing prioritization of these patients for
alternative agents. Further study in larger cohorts including
patients from additional ethnic groups will confirm the
predictive utility of such an algorithm. The simple nature
of our proposed model (clinical features able to be tested
in any setting plus a single polymorphism) makes this work
relevant to resource-limited settings where d4T use remains
common and such a tool is most urgently needed.
Acknowledgments
The authors thank Dr. Budiman Bela (University of
Indonesia) for provision of laboratory facilities, Steven
Roberts for assistance with genotyping, and all patients
who participated in this study. The work was supported by
Bristol Myers Squib and the Australian Centre for HIV and
Hepatitis Research (ACH2). This work formed the basis of
an oral presentation at the 4th International AIDS Society
Conference in Sydney, Australia, July 2007.
Disclosure Statement
No competing financial interests exist.
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of neuropathy were assumed to have developed after
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diagnosed here with neuropathy believed their symptoms
may have predated their d4T exposure. However, any
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independent of the risk factors considered and thus can
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and predicts an individual’s NRTI-SN risk. AIDS
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Evaluation of a clinical screening tool for HIVassociated sensory neuropathies. Neurology
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Address reprint requests to:
Catherine Cherry
Burnet Institute
GPO Box 2284
Melbourne, Victoria 3001, Australia
E-mail: [email protected]
Intervention / Programmatic Issues
Endang R Sedyaningsih-Mamahit1
1
Jakarta Provincial Health Office, Jakarta, Indonesia
Southeast Asian J Trop Med Public Health. 1997 Sep;28(3):513-24
SEAMO Regional Tropical Medicine and Public Health Network
291
Clients and Brothel Managers in Kramat Tunggak,
Jakarta, Indonesia: Interweaving Qualitative with
Quantitative Studies For Planning STD/AIDS
Prevention Programs
Abstract
Clients and brothel managers are often the most powerful decision-makers regarding condom use in brothels, but since publicly promoting
condom use is still “culturally” difficult in Indonesia, the most feasible way of reaching clients is through the female commercial sex workers
(FCS Ws) and their managers. The existence ofquasi-official brothel complexes in many major Indonesian cities, however, does make the
government a key player in promoting condom use within these complexes. Interweaving qualitative with quantitative studies, this paper,
which is part of a larger study, reveals the FCSWs’ client/managers-related determinants of condom use. Policies that will promote condom
use in brothel complexes are critical to the prevention of the spread of HIV throughout this community, as well as from it to the greater
community.
Introduction
As of November 1996 the official number of HIVpositive and AIDS cases in Indonesia was 449, 108
ofwhich were full-blown AIDS (Ministry of Health,
1996)_ Although estimates and projections of HIV/
AIDS cases in Indonesia made by various institutions
predict a grim future, the present sero-surveillance
system does not allow us to monitor them. Present
data do show that AIDS in Indonesia is predominantly
heterosexually transmitted (Ministry of Health,
1996).. As such, due to the nature of their work,
female commercial sex workers (FCSWs) are among
the communities at high risk to contract and spread
the HIV infection.
Previous limited studies in some major Indonesian
cities between 1991-1993 (Jakarta Health Provincial
Office, 1988-1995; Van der Sterren et a!, 1995) shown
that the prevalence of gonorrhea and syphilis among
brothel and non-brothel FCSWs were high (30-60%
and 3-15% respectively). Moreover, other studies
(Basuki. 1991; Rahardjo, 1992) have shown that the
condom-use rate was low in FCSW communities (1326%). Taken individually and together, both rates
indicate that the spread of HIV might indeed become
rampant among FCSWs and their clients.
The Indonesian government’s policies towards
prostitution and prostitutes have largely been determined by health and public-order considerations
(Jones et a!, 1995). Besides some detention-like FCSW
rehabilitation centers, many major cities localize
prostitution and place it under the control of local/
provincial governments. In these quasiofficial brothel
complexes, the FCSWs and brothel managers carry
out their business under some restrictions. Health
services and vocational training are usually provided
in these complexes; in general, however, they are
half-hearted attempts, at best.
Various studies from other parts of the world show
that very often it is not up to the FCSWs whether
the clients wear condoms or not during the sex
they have purchased (Mhalu et al, 1991; Pickering
et a!, 1993): the two most powerful decision-makers
are usually the clients themselves and the brothel
managers. Unfortunately, in Indonesia, it is still
difficult to promote condom use publicly, since
it is not “culturally acceptable” (Indonesia Health
Minister Suyudi, 1995). The easiest way to reach the
clients therefore is, through the FCSWs. However,
the structure of quasi-official brothels makes the
government another important player in this
scenario, and their policies and programs, or the lack
thereof, potentially determine condom-use practice
in the brothel setting.
Interweaving a qualitative study with a behavioral
survey, in 1995 I investigated the determinants of the
STD/AIDS-related behaviors of the FCSWs in Kramat
Tunggak, the only quasi-official brothel in Jakarta.
This was the first comprehensive study conducted of
a brothel community iQ Jakarta and stress was placed
more on factors that are modifiable. As the results of
293
Clients and Brothel Managers in Kramat Tunggak,
Jakarta, Indonesia: Interweaving Qualitative with
Quantitative Studies For Planning STD/AIDS
Prevention Programs
the study have been reported in several papers, this
paper is mainly based on the qualitative study of the
clients and the brothel managers.
Study site
Located near the harbor, Kramat Tunggak is officially
divided into 8 neighborhoods, with a total area of 11.5
hectares (28.4 acres). The FCS W population fluctuates
yearly; in 1995, when the study was conducted, there
were exactly 1,600 women working for 228 brothel
managers in this complex. The sociodemographic
characteristics in Table I give a picture of the FCSW
community in Kramat Tunggak based on the 1993
census. Government control is handled by the Jakarta
Social Welfare Provincial Office (JSWPO), but the daily
activities are handled by a JSWPO subsidiary referred
to as Panti, whose office is located across the street
from the brothel complex. Adjacent to the office are
classrooms where the vocational training is held.
Kramat Tunggak is a highly regulated place (Jakarta
Social Welfare Provincial Office, 1993). For example,
all the FCS Ws are called anak asuh, which literally
means “foster children,” and the brothel managers
are Ibu/Bapak asuh, or “foster mother/father,” and
only 18-to-35-year-old FCSWs may work in Kramat
Tunggak. They may do so for a maximum of 5 years,
or untiI they reach the age of 35, whichever comes
first. Similarly, brothel managers are allowed to
manage only one brothel, which they may do for a
maxium of 8 years. To help prevent client violence
towards the FCSWs, guns, knives, illicit drugs, and
alcohol (except beer) are prohibited; every brothel
has this announcement posted on its walls. On the
doors to the women’s rooms, some managers post
another announcement, which says something like:
“Sorry, for security sake, your door will be knocked
on every half hour.”
Study population and process
This paper gives some of the results of a oneyear study conducted in 1995, whose objective
was to study the determinants of the FCSWs’ STD/
AIDS-related behaviors (other results are reported
elsewhere). During April-November 1995, our team
conducted.459 structured-questionnaire interviews,
collected blood and urethral discharges from 282
FCSWs for gonorrhea and syphilis tests, and conducted
the qualitative study. The methods used for the latter
were participatory observation, interviews, in-depth
294
interviews, and focus groupdiscussions (FGDs). The
characteristics of the study participants are listed in
Tables 1, 2.
Two of my assistants were FCSWs, who had
volunteered to help negotiate my entry to the community. They introduced me to their friends and to
be interviewed, but the others agreedto answer our
short-structured questionnaire. Two older and one
younger client agreed to talk more freely, provided
they were not recorded. The characteristics of the 46
client participants are shown in Table 3.
some of the brothel managers, which greatly eased
my entry process. They also helped me in finding
specific cases, such as women who gave oral sex
(which is very uncommon there; see Table 5), and the
manager of the smallest brothel. While I conducted
my interviews, they chatted with other FCSWs in the
same brothel, and their stories complimented and
validated my findings.
The clients were conveniently selected and interviewed in the evening. The interviews were
conducted by four women, including myself; we
would request that the brothel managers allow us
to enter and mingle with the FCSWs and guests for
about 30 minutes. We chose places where the music
was not too loud and where the guests were not too
drunk. Half of the guests we approached declined to
For this study, an even distribution among the
brothel-manager participants was planned based on
age, sex, ethnicity, and years of working in Kramat
Tunggak, and I asked the Panti officers to provide a
list of those who matched each criterion. Some of
the managers refused to participate, however, while
others were very hard to meet; I therefore ended up
with 12 managers whose characteristics are shown in
Table 4.
Univariate, bivariate, and multivariate analyses
were performed using STATA 4.0 (Stata, 1993) for
survey data. All transcripts were analyzed using
categorization and contextual ization method (Kirk
and Miller, 1986; Miles and Huberman, 1994).
295
Results
Types of clients
From the FCSWs’ point of view, clients can be divided
into 3 categories: occasional clients (tamu), whom
they have served once or twice; regular clients
(kenalan), who have visited them 3 or more times over
a relatively short period of time; and lovers (gendak),
whom they treat as their husbands. To become a
regular client, not only must a man be satisfied with
the FCSWs’ appearance and service, but the FCSWs
must also like the man’s condition (eg his cleanliness,
kindness, generosity).
in Kramat Tunggak who on average received one
client per night, indicates that a vast numberofmen
frequent FCSWs in Kramat Tunggak.
Both the client and FCSW data showed low condom
use: 64% of the 46 clients had never used condoms
in any of their sexual contacts with the FCS Ws in
Kramat Tunggak (Table 3), and 25% of the 459 FCSW
respondents had never used condoms over the
previous two weeks (Table 5). Noteworthy points in
this regard were that most of the clients said that
the women did not ask them to use condoms, and
in-depth interviews with 30 FCSWs revealed that
many of the women were too embarrassed to put the
condom on - the clients had to do it themselves.
Many of the kenalan treat the women as their
concubines, whom they visit once or twice a week.
Having a gendak is also common in Kraniat Tunggak, even though it is formally forbidden, due to the
troubles it can cause. The gendak’s payment system
was different from that of the other clients: they only
paid the manager’s share when they visited, and
would pay the women monthly, or at greater intervals.
The women did not mind this, because when the
gendak did pay, it was usually a lot of money. Many
said they did not calculate how much the men owed
anymore, and that they would understand it if the
men had no money. I found some women who not
only supported their gendak, but his family as well.
One FCSW strongly maintained that life in Kramat
Tunggak without a gendak is ,.saltless.”
The brothel managers in Kramat Tunggak
In contrast to what is commonly believed, only a
few brothels served foreigners. FCSWs and brothel
managers both said that they refused for eigners
(white and Asian) because they were afraid of disease,
and because they didn’t know how to communicate
with them. This seemed to have long been the
practice, but it was not clear whether the fear of AIDS
had. increased it even more. In Kramat Tunggak,
foreigners were usually guided by local people, who
know exactly which brothels were open to them.
There were no ready data about the sex distribution of
the managers; however, the 1993 Panti census noted
that about 17% of the managers were widows, and
Panti officers estimated that 50% of the managers
were women (Hardjono, 1995). It is uncommon for
male managers to have sex with their own FCSW
employees in Kramat Tunggak, since it was believed
that this practice brings bad luck to the brothel’s
business. Some may have FCSW lovers from other
brothels in Kramat Tunggak, but many have wives
who are also active in managing the brothel.
Our survey showed that during the previous two
weeks more than 80% of the FCSWs had had one
client or less every night (Sedyaningsih, unpublished), although 2% said that they had received
more than 3 clients per night. Our interviews with
the 46 conveniently selected clients indicated that
only about 43% of them visited Kramat Tunggak 3
times or more per month, while 17% said that they
visited every night (Table 3). This client frequency
per month, plus the fact that there were 1,600 FCSWs
296
A small number of interviews with clients gave the
impression that older men were more reluctant to
use condoms than younger ones. A mid-forties client
laughed at the idea:
I came here to have fun, to enjoy myself Using condoms
is not normal. No normal men will wear that. I ask you
now: do you, yes yourself use a condom?!
On the other hand, a young man said hesitatingly:
Well, if it is a must, I mean if it is the regulation here, I
think I won’t mind using a condom.
The characteristics of the 12 purposive brothelmanager participants are shown in Table 4. Most of
them were indifferent about condom-use practice,
and only a few supported it by providing condoms
in their brothels.
Types of brothels
In general, the brothels in Kramat Tunggak can be
divided into 3 types. The first is a “bar-like brothel”
with loud music and flashing disco lights, where the
managers make money from selling beer and other
drinks, and by providing women for sex. The women
have to pay the manager monthly for electricity, and
in some, for water and food, as well. The. room rents
are paid by the women’s clients; an overnight client
has to pay about 3 times as much as a short-time
client. Clients pay the FCSWs directly; the room rent
is about one-third of the amount actually paid to the
women. In bar-like brothels, women can also make
money from tips, for accompanying the guests in
drinking and dancing, which they don’t have to share
with the manager.
The second type is the “bar-brothel” type, which is
also characterized by music and dancing, though
not as much as the first, and is usually smaller. The
managers mainly make money from the sex trade,
although they also sell drinks. The third type could
be called a “pure-brothel.” Usually small (though not
necessarily so), it has no music and no dancing: it is a
place where men go solely for sex.
Kramat Tunggak has market prices for both shorttime and overnight clients. When this study was done,
short-time and overnight clients paid Rp 15,000.00
(USS 7.00) and Rp 40,000.00 (US$ 18.00) respectively.
These prices are not written down anywhere, but are
widely known and followed.
How the brothels were run in Kramat Tunggak
After analyzing my interviews with the managers and
the FCSWs, as well as the FGDs with FCSWs, I ended
up with a categorization that divided the brothels
into 4 types ofmanagement. The characteristics of
each category were based on the strength of the
regulation, the amount ofthe managers’ attention
given to the FCSWs, and the FCS Ws’ autonomy in a
particular brothel. However, one can find brothels
that have the characteristics of more than one
category. It should also be noted that the way the
brothels are managed has little to do with its type;
consequently, one can find, for instance, barlike
brothels, bar-brothels, and pure-brothels, that are
managed in a paternalistic style.
Paternalistic brothels
These brothels are characterized by strict regulations for their FCS W employees, and by the managers paying close attention to them. Women in
these brothels have little autonomy; the managers
think they know what is best, and admit that they
are sometimes hard on the women. They maintain,
however, that this is for the women’s own good. The
Red Dusk brothel: This brothel (not its real name) was
a typical example of a paternalistic brothel. It was run
by a couple, Jbu and Bapak (mother and father), who
received the brothel as a gift from someone Bapak
had helped about 4 years previously. Since then, the
couple has worked hard to make it a success, and
they have bought and renovated several adjacent
buildings. Their brothel was of the bar-like type, with
3 floors (the upper floors were the women’s rooms), a
spacious dancing area, and flashing lights.
There were about 16 FCSWs working there, all of
whom were from East Java (both Ibu-Bapak came
from that province, as well). There were also 2-3
males who worked as waiters, and a transvestite
who worked as the bartender. Jbu told me that every
other month she would visit their hometown. Everybody in their area knew that they had a brothel in
Jakarta, so Ibu often found that women, either alone
or with their parents, were waiting to apply for work
as sex workers. She liked to choose the beautiful and
obedient ones. On rare occasions, when she had to
find new FCS Ws by herself, she would do so among
the small illegal brothels along the roads near her
hometown.
Bapak-Ibu provided rooms furnished with a large
spring-mattress bed, mirror, fan, lamp, and a small
corner in which the clients and women could wash
297
themselves. Ibu provided food, but the women could
either eat inside (with payment), or find their food
outside. Ibu also provided laundry service. The FCSWs
did not have to pay for the room, but each woman
had to pay Rp 50,000.00 per month (USS 22.00) for
the electricity (lamp and fan) and laundry. If a woman
had other electronic appliances, such as a TV or radio,
she had to pay about USS 10.0-USS 20.0 more.
Bapak had had military training when he was young,
and he had formulated a number of regulations that
he tried to apply to his brothel. The women had to
wake up early, and by 08.00 hours everyone had to
have finished their bath and breakfast and open their
rooms. He said this was to “let the sun kill the bacteria
inside”. The women could nap in the afternoon, but
by about 19.00 hours everyone hadto be ready for
the guests. The women were allowed to drink beer
with the guests, but they were not allowed to get
drunk. The women were not supposed to smoke in
their rooms, and they had to pick up their clients’
cigarettes stubs forcleanlincss and to prevent fire.
For safety, Ibu would hold the women’s roomkeys at
night, and each time a FCS W received a guest she
would get the key from Ibu. In this way, Ibu could
count all the clients who had sex and see how long
it was before the key was returned. After the sexual
encounter, the guest was not allowed to walk out by
himself: the woman had to accompany him, so that
Ibu-Bapak would be sure that nothing had happened
to her. Ibu-Bapak did not mind if a woman refused
to serve a client, so long as it was courteously and
wittily done, and they even taught the women how
to do it. In short, there were a lot of regulations in
this brothel, including some very minute ones, and
if Bapak found that a FCSW had broken the rules, he
would fine her.
Bapak had a private paramedic to whom he sent his
employees for check-ups, but being a good citizen,
he also required the women to attend the JSWPO’s
monthly health check-up. Bapak said he advised
the women to use condoms, but he did not provide
them. I think that Ibu-Bapak believed that the
paramedic could solve any STD problems better than
any condom could.
As usual, clients would pay the woman directly. She
had to give half to Bapak, but could manage the
other half herself. Bapak would take two-thirds of his
298
share for “managerial costs” and keep the other third
for the woman’s savings. If she needed money for
medical treatment, she could use these savings. The
women could also ask Bapak to keep more than the
compulsory amount, because he would only let his
employees go home to visit their villages after their
saving had reached one million rupiah (US$ 444.00;
usually after 3-4 months). Bapak said it was no use
for the women to bring less than one million rupiah
home, as she would not be able to buy a cow. He
liked to see the women give their parents substantial
economic help. His own monthly income from the
brothel (from the women and from selling drinks)
was an average of Rp 6,000.000.00 (US$ 2,666.00),
and this brothel was indeed one of the busiest in
Kramat Tunggak.
Both Bapak-Ibu believed that it was bad luck for a
manager to have sex with his employees, and in this
brothel, even the male workers were not allowed
to have sexual relations with the FCSWs. They were,
however, allowed to have lovers from other brothels.
In accordance with JSWPO regulations, Bapak strictly
prohibited the women from having lovers (gendak)
among the clients.
Familial brothels
The second type are brothels that have a family
atmosphere. The managers are like parents to the
women: full of regulations for the sake of the women,
and full of kind attention. The difference between
this type and the paternalistic brothel is that in this
system the women have more autonomy: as in many
Indonesian families, they can argue and break some
of the rules if they do not like them. The Soft Wind
brothel: Soft Wind (fictitious name) was a mediumsized, bar-brothel type, that was run in a familial
way. The manager was an elderly lbu; her husband
managed another brothel not far from there. Neither
brothel was theirs; they leased them from a Mr 1, a
Chinese-Indonesian businessman who owned about
12 brothels in Kramat Tunggak. lbu had started in the
brothel business 17 years ago outside KramatTunggak.
She was an exFCSW herself; she did not do it for long,
however, because she immediately recognized that
managing a brothel, even a very small one, was
more profitable. She started out leasing a small room
near a train station, and employed two FCSWs. Their
previous brothel, located outside Kramat Tunggak,
was in an area where the government had planned
lbu was very strict about gendak, as she had seen too
many of them take advantage of the women. I f she
saw that a woman had started to become too close
to a client (if the man stayed several days and nights
with her, for instance), she would ask them whether
they were planning to marry. If not, she would
reprimand and threaten the woman.
to build a highway, so they were offered a space in
Kramat Tonga and given a small amount of money
in compensation. They had now been in Kramat
Tunggak for 8 years. Besides leasing the brothels,
the couple owned a house outside Kramat Tunggak,
where their children lived. Their children (adults now)
knew that their parents managed brothels, and they
sometimes came to visit.
Located in the middle of Kramat Tunggak, Soft Wind
was not a very busy brothel. It had 7 FCSWs and one
male worker. Although lbu came from Central Java,
her employees were from West, Central and East
Java. She never tried to recruit new workers, because
there were too many times that she had paid the
woman’s travelling expenses, only to have her work
for a short time before returning to her village. lbu
just waited, and from time to time, a woman would
come and ask to work for her: either somebody from
another brothel in KramatTunggak or from other
brothel complexes. Ibu was not choosy, as long as the
women had a letter proving that they were widows/
divorcees, or (this was her term) “blemished girls.”
lbu provided only modest beds for each room. The
FCSWs could get up at any time they liked, but they
had to be ready for the guests by early evening.
They were free to drink and smoke, but lbu would
not tolerate illicit drugs. She did not strictly knock
on the women’s door every half an hour when they
had clients with them, but she did watch over them
carefully for their safety. She would take the women
to the hospital if they were sick, and she did not mind
if the women rested up in her brothel during the
illness, lbu also advised her workers to use condoms,
For every sex client, no matter how much he paid,
the FCSWs had to pay lbu Rp 5,000.00 (USS 2.50): on
average, this was about 25% of what the client paid.
The women did not have to share their tips; if Ibu
saw that a client had already drunk for hours with
a woman, she would give the client a hint, so that
he would not forget to tip the sex worker. This was
necessary, because many of the women were too
shy to ask for tips. They told me that it was up to the
clients; they just hoped that the men “understood”
them. The FCSWs had to pay about US$ 1.50 more
per month for electricity. They were free to manage
their own money, and all of them bought their own
food, paid for their own laundry, and bought the
water for their baths. lbu’s principle in running the
brothel was: “The manager and the sex workers should
work together for the benefit of both.”
Laissez-Faire Brothels
This is the most lax type of brothel. I did not find
any bar-like brothels in Kramat Tunggak that were
run in this manner, though this does not mean that
there weren’t any. The managers did not regulate
the women strictly, because they basically cared little
for them. The FCSWs had the greatest amount of
autonomy here, though there were some restrictions.
The Wild Horse brothel: This brothel (not its real
name) was strategically located on a corner. It was
of the bar-brothel type, and the manager, an elderly
299
and she did provide them; whether they were actually
used or not, she left to the FCSWs and their clients to
decide.
woman, did not live there. She leased it, again, from
Mr J, her ex-husband (they had divorced not too long
ago) leased a brothel close by. Both had previous
brothel-management experience elsewhere, and her
nephew managed the brothel’s dayto-day business
for her. This young man did not live inside either,
but he came everyday, from morning till evening.
He had 2-3 male workers who stayed all the time
in the brothel, and they functioned as bartender,
disc-jockey, waiters, and bodyguards. There were 9
FCSWs working in this brothel, most of whom came
from a small island in East Java, the same as Ibu and
her nephew, who was called Kakak, which means
“brother.” With about 15 clients per day, this brothel
was not a very busy one. As in familial-style brothels,
the FCSWs shared approximately 25% of what the
client paid with the manager. The FCSWs also had to
pay for electricity, which varied according to what
appliances they had-this is the most common system
in Kramat Tunggak. Most of the clients came from
the same small island; these men, even in a place like
Kramat Tunggak, were notorious for their bravado
and rudeness. Some of the FCSWs informed me that
the clients from this island often initiated fights in
brothels, but when I asked about this, Kakak assured
me that they all behaved nicely in the Wild Horse,
because the owner was from the same tribe.
Kakak had only been in this business for two months,
and he said that he would only help his aunt for a
year. He did not enforce any regulations beyond the
formal ones; he did not care whether the women
woke up early or not, whether they were ready for
the guests on time, whether they drank, smoked, or
took illicit drugs. Here, each FCSW was on her own.
(What about condoms?) Sure, the women could use
them if they and the clients wanted. (Do you advise
them to use a condom?) Heck..., no! It’s too personal. I
don ‘t talk about such matters with them.
(May the women have a gendak?) Why not? It’s also a
personal matter. As long as the men pay for the room
each night they spend here.
(What ifa FCSW gets sick?) Well, they better go see a
doctor, and take a rest in their own village.
Kakak told me that he was not interested in the
women in Kaamat Tunggak. He had a wife, who did
not know about his job here, and a child.
300
Business brothels
The last category consists of bar-like or barbrothel
types that are managed more professionally. On
average, they have strong-to-moderate levels of
regulations, the managers pay a moderate amount
of attention to the women, and the women have a
correspondingly moderate level of autonomy. The
emergence of this category of brothel within the last
5 years or so indicates that prostitution is starling to
be seen as a safe business in Jakarta.
The Dream Castle brothel: Dream Castle (fictitious
name) was a very big, bar-like brothel. It had about
60 FCSWs, and the owner, Mr A, was a man of about
45. He set a new precedent in Kramat Tunggak about
two years previously by buying-up 7 or 8 brothels at
once. Being a successful businessman in several other
sectors, he felt challenged to try his luck in the sex
industry. Besides owning brothels, he also managed
some of the beer distribution in Kramat Tunggak.
He lived outside the complex and refused to tell me
how much he earned from his businesses in Kramat
Tunggak.
Mr A employed several men and women as managers
of his brothel, and he married one of them, a young
woman from Indramayu, The one who managed
Dream Castle was a woman of about 45, who was
called Mbak (sister); together with her first husband,
she was an ex-brothel owner, as well. After her divorce,
she bought her own brothel and married again.
Unfortunately for her, this second husband was not
used to the life in KramatTunggak, so she soon had to
abandon her business. Now that he had passed away,
she had come back to Kramat Tunggak, but did not
have enough money to own a brothel herself.
Mr A did not require his sex workers to pay for
electricity or water, though the women had to sharF
25-30% of what the sex clients paid them. Dream
Castle was one of the busiest brothels in Kramat
Tunggak. On average, the women in this brothel
their skill in applying them. One of the significant
negative factors, on the other hand, was the women’s
perceptions about the clients’ and the managers’
rejection of condom use.
Mr A said he cared for the safety of his women by
providing a health fund. He mentioned how he had
paid Rp 1,800,000.00 (USS 800.00) for one of his
FCSW’s operation. He even called the woman over, to
tell me the story herself. It appeared to me that Mr A
used his “charity” to gain power over the women: they
felt in debt to his generosity, and were uncomfortable
with him. For examle, in the morning they usually sat
in the guest room watching TV, but whenever Mr A
visited, they would silently slip away. Many told me
privately that they preferred to use their own money
forgoing to the doctors than to use the fund.
The qualitative section of the study complimented
these findings: most clients did not use condoms
(almost all said condoms decreased sexual satisfaction), and most brothel managers did not provide
condoms in their brothels-many had never even
discussed it with their FCSW employees. Many of the
women did not have the knowledge and/or skills
(techniques or negotiating skills) to overcome these
core problems; furthermore, some did not have the
confidence or the autonomy to negotiate condom
use; and some would get too drunk or too desperate
for money to bother about condoms.
Mr A and Mbak were skeptical about condom use.
Their attitude was that it was impossible to promote,
because the clients did not like it; on the other hand,
they assured me that they advised their workers to
use condoms, although they did not provide them in
the brothel. In short, the owner’s and the manager’s
regulations and attention were for the benefit of the
business, not because they cared for the women.
The image of condoms has never been positive
in Indonesian society, even for family planning
purposes. It is more taboo to discuss condoms openly
then other birth prevention devices, and a number
of humorous euphemisms are used so as to avoid
explicitly mentioning condoms (eg, rubber sarong,
raincoat). Therefore, it is important that our`survey
found that young women tend to use condoms more
consistently than older ones (Sedyaningsih, 1996,
unpublished paper) and this study also found that
younger clients were more likely to be persuaded to
use condoms. The most probable reason for this is
that younger people are the product of recent times,
in which the media has already discussed the danger
of AIDS and condom use as a prevention method,
albeit in limited ways. Consequently, they are likely
to be more comfortable with the idea, since they did
not grow up in an era when discussion of condoms
was taboo.
From the interviews with FCSWs and managers and
from the FGDs, it is evident that the majority of the
brothels in Kramat Tunggak were run in a familiar
way. Our quantitative data also showed that, on
average, the FCS Ws had to share about 30% of their
monthly income with their managers, which included
room rent and electricity. This confirmed that most of
the women in Kramat Tunggak had relatively strong
autonomy in managing their own income; it also
shows that there were not many paternalistic and
business brothels, which demanded more money
from the women.
Discussion
A survey (Sedyaningsih, unpublished data) found
that the significant positive factors for predicting
continuous condom use among FCSWS in Kramat
Tunggak were the women’s previous experience
in negotiating condom use with clients, and their
experience in using condoms for family planning
purposes. These experiences were, in turn, positively associated with the FCSWs’ knowledge about
STD/ADDS, their positive beliefs about condoms and
Indonesia has achieved great success in its family
planning programs by, among other things, changing
the public norm from“many children bring prosperity”
to “a small-sized family is a happy and prosperous
family.” In this era of AIDS, the government (the JS
WPO and Panti) can use similar tactics, by improving
the image of condoms in Kramat Tunggak and other
quasi-official brothel complexes. They should change
their present indifferent attitude about condom use,
and try to create a new public norm (within brothels)
that using condoms in brothels is the “smart” thing
by stating formally that all sexual intercourse taking
301
earned Rp 500,000.00 (US$ 222.00) per month or
more. Mbak received only USS 80.00 per month from
Mr A, but with tips from guests, she could eant about
the same amount as the FCS Ws.
place within quasi-official brothel complexes, whether
it involves clients or lovers, should be conducted with
the use of a condom. A large announcement board
should be placed at the entrance to the complexes,
along with a kiosk that distributes STD/AIDS information and sells or freely distributes condoms.
Furthermore, the JSWPO/Panti should require the
managers to post this announcement on every
woman’s door and on the wall of the women’s rooms
as an addition to its other announcements. They
should also make condom-provision in each brothel a
regulation rather than an option. The brothels should
be regularly checked, and those that do not comply
should be penalized. Checking brothels is a routine
procedure in Kramat Tunggak, and the officers
can always find something wrong (eg, outdated
operating licenses, no building licenses). In this way,
the FCSWs will be more encouraged to bring up the
issue of condom use with their clients - and may even
persuade them to use them.
It will take some time for the women and the clients
to really use condoms in their transactions, but
informative posters and booklets in each brothel will
be very helpful in accelerating the creation of this
new norm. It is best that JSWPO/Panti not penalize
the women Who are found not to use condoms;
instead, they should be encouraged to explain their
reasons for doing so.
Condom-use policies cannot and should not be Vol
28 No. 3 September 1997 the only strategy to prevent
the spread of HIV in brothel communities, as it also
should be realized that-brothels are not the sole
place where we should put our efforts to prevent the
AIDS epidemic in the country. As was mentioned in
the recent XI International Conference on AIDS (July
1996), the other two strategies of the three-pronged
method for preventing/containing the AIDS epidemic,
disseminating STD/AIDS-related knowledge, and
STD control) should also be conducted in all brothel
communities.
Developing programs for the above two strategics should make use of this study findings, as well.
For example, disseminating STD/AIDS knowledge
in brothel complexes should involve the brothel
managers. In this, the STD/AIDS educators/trainers
must be made aware of the differences among each
brothel management’s style, and approach them
302
accordingly. The familial brothels are probably the
easiest to approach, since the managers basically
care for their employees. By discussing STDs, AIDS,
and condom use with the FCSWs, they may come
to their own solutions as to how best to promote
condom use in their brothels. Paternalistic brothel
managers can also be a great help in ensuring that
FCSWs practice condom use, as long as tliey are first
convinced of its importance. Since most of them
are older, experienced, and have or used to have
“respectable” jobs, a more personal approach to them
at a separate time is necessary. Problems may arise
with the business-type and laissez-faire managers,
but stressing how good for business it is to have
healthy FCSWs may work well.
Government regulations on condom use can only be
implemented in places where they have strong grip,
such as in quasi-official brothels; therefore, further
interwoven qualitative and quantitative studies of
non-brothel FCSWs (eg, street FCSWs and covert FCS
Ws) are very important to plan STD/ AIDS prevention
programs in these communities. However, as quasiofficial brothels are usually large and located in major
cities all over Indonesia, building a new condom
norm here may gradually have an impact on other
types of FCSWs, as well.
Acknowledgements
This study was partly funded by the Indonesian
government through the Overseas Training Office-.
BAPPENAS. I am grateful to Dr Kris Heggenhougen,
Dr Steven Gortmaker, Dr David Hunter, and Dr Grace
Wyshak of Harvard School of Public Health for their
advice in conducting this study, and to Donald
Halstead who edited this work.
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Office) Personal communication, 1993.
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Translated from Studi Evaluasi Pelatihan Penatalaksanaan PMS dengan Pendekatan Sindrom di Beberapa Kabupaten di
Jawa Timur.
Cholis Bachroen2
1
2
Center for Health Services Research, National Institute of Health Research &
Development, Surabaya, Indonesia.
Bul. Penelit. Kesehat. 3 (1) 1999: pp.50-65
305
Evaluation of Training for Sexually Transmitted
Disease (STD) Treatment Using Syndromic Approach
in Several Districts of East Java
Abstract
Sexually Transmitted Diseases (STD continue to become major public health problems. Most of STD patients present with urethral or vaginal
discharge, even though the causes may be of different micro-organisms. The Syndromic Approach (SA) is ark algorithm for STD management
currently recommended by the WHO. Diagnosis are made based on clinical signs and symptoms using q certain flowchard-without laboratory
confirmation, and all possible causes will be treated. IEC are also given and the patients’ partners are notified. The East Java Provincial
health office has trained Puskesmas ‘and hospitals’ doctors and paramedics on this new STD management approach. The objective of this
study is to evaluate the implementation of SA in some Puskesmas and private clinics which personnels have been trained before. Using
direct observation, document research, interviews and focus group discussions, data and information on the benefit of SA, the obstacles
in implementing SA, and recommendations to improve the health providers’ performance in STD management are collected. Results are
hopefully used as inputs in improving the STD control program, provincially as well as nationally.
Sexually transmitted diseases (STD) are common and
frequently encountered illnesses that pose a serious
health problem in the society. Amongst women,
STD is the most important etiology of reproductive
tract infections which cause physical complaints,
psychological disorders, and disturbances in
one’s marital harmony.1 Twenty different types of
microorganisms are known to be transmitted through
sexual intercourse.2 Unfortunately, most STD are
presented with the same symptoms and complaints,
even though caused by different etiologies. For
example, discharge from a male’s urinary tract or a
woman’s vagina, and genital ulcer disease can be
caused by a host of microbes.
The Syndromic Approach is a treatment schedule
for STD which has lately been recommended by the
WHO.3 Using this method, diagnoses of STD are made
based on the patients’ complaints and symptoms,
with the help of an algorithmic chart. Medication is
given to all those found with syndromes, and also
given to the patient’s sexual partners. The Syndromic
Approach possesses the IEC element to decrease risk
of re-infection and increase compliance, and must be
supported by adequate medicines.
To facilitate this program, training was given to health
care workers. In the East Java province, trainings
were initially given directly by Subdit Pemberantasan
Penyakit Kelamin dan AIDS, Ministry of Health, in
1998, then continued by East Java’s provincial health
office in 1999. This study aimed to evaluate the
implementation of STD treatments at several clinics
and primary health care centers (or puskesmas) which
had employed trained medical officers. The study
hoped that syndromic approach had strengthened
the overall STD treatment program.
Due to financial limitations, the study was conducted
at 3 locations in East Java, which were: Surabaya,
Pasuruan, and Malang.
Objectives
The objectives of this study were:
1. Evaluate STD treatment using the Syndromic
Approach done by doctors/paramedics of clinics/
puskesmas where one of the staff had already
been trained.
2. Study the obstacles in applying the Syndromic
Approach method.
3. Suggest inputs for the program to improve
treatment of STD in general, and using the
Syndromic Approach in particular.
Methodology
The study was carried out in the East Java province:
Surabaya, Pasuruan, and Malang regions, between
March and April 1999. The study population was
doctors and nurses at puskesmas and private clinics
where one of the staff had been trained to treat STD
using the Syndromic Approach (SA).
Structured observation was directed at the doctors’/
paramedics’ methods of treating STD. Locations of
307
Evaluation of Training for Sexually Transmitted
Disease (STD) Treatment Using Syndromic Approach
in Several Districts of East Java
these observed doctors/paramedics were selected
purposively, which were puskesmas and clinics
according to data obtained from East Java’s local
Health Ministry’s Office. At each location, the
doctors/ paramedics who examined the patients
were observed. Structure of the observation was
developed from instruments made by WHO.
doctor. On the third day, observations were done at
4 locations by 4 teams, while the remaining 2 teams
joined the DGD in Malang. The doctors’ tasks in these
teams were to observe the examination of patients
by doctors/paramedics in those puskesmas and to
interview afterwards. Remaining team members
carried out document assessments.
Doctors and paramedics at each location were
interviewed to obtain information regarding ease
and difficulties in implimenting the SA method.
Assessment of the documents was done on patients’
daily reports, medical records, and daily lab reports
before and after the training.
To reduce observation bias, this research team
obtaine dapproval of the Chairman/Head while
staff were only informed that the team would be
conducting general observation. Observations
were held from 08:00 am until no more patients
arrived. If during that time another patient with STD
complaints (besides patients brought by the teams)
appeared, observations were also made during their
examination. When the last patient was finished being
examined, the doctors/paramedics were informed of
the true objectives of the observation team.
Focused Group Discussions (FGD) were held with
the doctors and paramedics at Malang (they were
not observed) to obtain information regarding
the training process, advantages, and obstacles in
carrying out the SA method.
Results
Observation
During the study, structured observations were
successfully done for 15 doctors and 1 paramedic at
Surabaya and Pasuruan. Details of the locations were
as follows: at Surabaya: Puskesmas Mulyorejo, Pusk.
Krembangan Selatan, Pusk./RS Tambak Rejo, Pusk.
Sawahan, Pusk. Pegirian, Pusk. Banyu Urip, Pusk.
Putat Jaya, Pusk. Tanjung Sari, Pusk. Benowo, Pusk.
Manukan Kulon, Pusk. Dupak, Klinik PKBI, an Klinik
Prospektif. At Pasuruan: Pusk. Prigen, Pusk. Purwosari,
and Pusk. Sukorejo.
To ensure the presence of patients with STD
complaints (especially white discharge), the
research team at Surabaya collaborated with a social
organization (Lembaga Swadaya Masyarakat or LSM)
which had the IEC program among sex workers
or prostitutes, whereas at Pasuruan patients from
bordellos (residencies of sex workers) were attending
neighbouring puskesmas. Usually those women
complained of mild to moderate white discharge,
and were asked to convey these complaints when
examined at those puskesmas. These women were
given money for transportation, examination, and
medicines, if given outside prescriptions.
On the first and second days, observation was
conducted at 6 locations by 6 different teams;
each consisting of 2 members: a doctor and a non-
308
In its course, either by intention or not (some patients
admitted to being asked by the LSM to come), several
puskesmas had knowledge of teams’ objectives
even before their arrival. Consequently there was
a puskesmas that posted the SA’s algorithm on the
walls of the examination rooms early in the morning,
and at several other puskesmas doctors were ready
with the SA book on their desks.
During those 3 days, observations towards 18 patients
were made: 15 women and 3 men. Unfortunately 2
female patients brought by the team gave different
complaints i.e. diarrhea. Although this meant
reduction of participants for the team, for these truly
ill patients there was a benefit since they received
free treatment for diarrhoea.
Analysis
During this evaluation phase several interesting issues
emerged. Generally the examination rooms were not
private enough, in the sense that conversations could
be heard by other people/patients. At puskesmas
where patients were crowded, 2-3 doctors worked
simultaneously inside a big room. At one puskesmas,
a street-merchant even entered that room.
Inside that open room, many doctors/examiners
lowered their voices while asking personal/private
questions, thus keeping a sense of confidentiality.
However, some asked loudly, resulting in patients
answering timidly.
The established diagnoses were quite varied (see
table 1), as also for the therapy given. Quite many
examiners gave therapy according to the SA method.
Unfortunately not all dosages were recorded by the
team and there were medicines that were hard to
read or the prescriptions used codes.
Physical examination
Findings in this phase included the fact that
several puskesmas didn’t provide special rooms for
physical examinations. Even if special rooms were
available, their functions were mixed with rooms for
injections, and in fact physical examinations were
rarely performed. Reasons included the inadequate
quality of the rooms, overcrowding, or the lack of
understanding for privacy. At private clinics where
we made observations, since they were specially
constructed for birth control or STD services, special
examination rooms always existed.
Examiners who performed physical examinations
performed them well: there was a third person to
accompany the patient throughout the examination,
the patients were asked to remove their underwear,
several were asked to lie in the lithotomic position
and had their inguinal glands palpated, and several
were inspected with speculums. A male patient was
asked to do “milking”.
Not one of the examiners washed their hands before
examination, but most didn’t forget to wear gloves.
After examination, every examiner washed their
hands.
IEC and Utilized Time
Generally examiners explained to the patients about
their diseases, although the time duration spent for
counseling was variable. The longest examination
(including IEC) done by a doctor who was aware of
being observed was 23 minutes. Two examiners spent
16-20 minutes, one of them being a doctor who had
worked at that puskesmas for less than a year (has not
yet received training on SA), and the remaining person
a doctor at a private clinic. Four people spent 10-15
minutes: 2 doctors working at private clinics, and the
2 other being puskesmas doctors who seemed alert
about the presence of patients’ white discharge and
addresses (localization areas). The rest (9 examiners)
commonly used around 5 minutes to examine and
give IECs. One person even took only 2 minutes. At that
puskesmas, chief complaints were recorded by the
nurses, and then instructed to go to the lab to check
for gonorrhea and sputum. After the results come out,
the doctors immediately prescribe therapies.
Diagnosis and therapy
We found examiners who collected patients’
discharges for testing at the labs, and there were
patients who had their venous blood drawn. However,
generally, doctors didn’t wait for the lab results to
prescribe medications.
There were 3 examiners who followed the algorithm
when performing examinations and treatments.
Although in several puskesmas posters of algorithms
were hung, such as treatment of anaphylactic shock,
dehydration, and pneumonia, rarely were the SA
algorithms put up.
Many examiners explained the prescribed medicines
and suggested patients to comply with the regimens.
Only a few advised patients to wear condoms and
no one explained the proper way to use them.
Most examiners instructed patients to come back
for followup. Not many examiners explained the
importance of treating the sexual partners or
offered to notify and examine the sexual partners.
But fortunately, 3 examiners made prescriptions for
the patients’ sexual partners: one doctor at a private
clinic and 2 puskesmas doctors (who weren’t aware
that they were being observed).
309
There were examiners who did not ask open-ended
questions or dug deeper, thus patients lost an
opportunity to explain their complaints. Besides,
there were other examiners who did not inquire about
their patients’ sexual activities, even though their
complaints may lead towards STD. This may be due
to the examiners’ mistakes or to the non-supportive
environment. This also applies to questions regarding
the patients’ sexual partners’, their activities and
condom usages.
Documents assessment
Records on types of diagnoses and therapies between
January-February 1998 (before the trainings) and
January-March 1999 (after trainings) were assessed.
At 2 private clinics improvement in diagnostic
quantity and quality were actually found (according
to SA), as well as the therapy were according to SA.
how diverse the (suspected) STD are labelled on the
medical record cards. Further, the reporting forms
did not facilitate optimal reporting of STD (Box 2).
Treatment regimens given to STD or suspected STD
patients in 1998 and 1999 were also assessed. At 2
observed private clinics there seemed to be a change
of treatment regimens in 1999 which was according to
SA. Meanwhile puskesmas showed diverse treatment
regimens, though commonly a change in regimens
between 1998 and 1999 was not found; or in other
words, puskesmas have not followed the treatment
regimens that are consistent with SA. Box 3 shows
several treatment examples given at puskesmas for
STD or suspected STD patients. It is important to note
that not all puskesmas treatment regimens could be
verified, because puskesmas use coded treament in
the registry books.
Laboratory
Besides the two private clinics which
had active laboratories, every observed
puskesmas possessed basic labs. Even so, the
activity levels at those labs in the sector of
STD varied. Some were very active, such as at
Pusk. Putat Jaya, Pusk. Sawahan, and Pusk./
RS Tambak Redjo; some were less active,
such as at Pusk. Dupak, Tanjung Sari, and
Pegirian; some only carried out non-STD tests; and
some performed no activities at all due to stockout of reagents. Not all lab workers were analysts,
furthermore quite many also double-worked as
administrative officers.
Interviews
Interviews were conducted with the observed
doctors/paramedics, as well as the Chairmen or
Heads of the puskesmas. The aims were to obtain their
opinions on training for the STD treatment using SA
method, benefits, and obstacles in applying this SA
method in their work places.
Besides that, 5 puskesmas showed records of
diagnoses that were more-or-less in accordance
with SA; general improvement also happened after
trainings. Three puskesmas had empty records both
before and after the trainings, 5 puskesmas presented
data matching the disease codes on LB1, and 1
puskesmas recorded the diseases by only writing
PMS. Box 1 shows the types of diagnoses that were
directed towards STD. From this table we can see
310
From 18 interviewed participants, 5 were doctors not
trained for STI. Amongst them were even those who
had not heard of the training at all, even though a
person within their puskesmas had received training.
Even so, from observations, the work performances
of those untrained doctors (with regards to STD
treatment) were far better and more consistent with
the SA method than those who had been trained;
for example, in analysis and providing IEC. Amongst
since it doesn’t require lab tests (even though lab is
present); c) medicines can be prescribed externally.
From those who’ve been trained, generally they
felt satisfied with the training method and felt
that training was beneficial. However, some had
complaints and suggested improvements. Below is
the list of stated complaints and suggestions. Since
interviews were conducted individually, this list is not
a collective consensus. Hence it’s possible that there
exist suggestions/complaints that were not agreed
by other participants.
Focused Group Discussion (FGD)
Complaints regarding trainings were: a) not enough
pictures/tools as demonstrative models; b) training
did not include clinical cases (although some
thought that practice wasn’t needed since they dealt
only with analysis); c) materials too crammed; d) lack
of practice laboratory at the puskesmas; e) not all
training modules were received (especially the last
SOP/books); f ) algorithms were too complicated; g)
book number 3 and 5 had same contents; h) duration
of training (5-6 days) was too long.
Meanwhile, the constructive criticisms suggested
were: a) in training the doctors and paramedics
should be separated, because many paramedical
questions were basic in nature, hence challenging
to a doctor; b) training should be given to those
who actually would examine and treat patients; c)
simplify the algorithm; d) duration of training should
be shortened to 2 days, but the training materials
have to be sent earlier; e) also insert the actions of a
specialist into the books, not enough to state that it
is recommended to refer to a specialist.
Arguments put forward when asked why the SA
method wasn’t applied, though previously having
gone through the training, were: a) too many patients
(1 doctor must examine 50-75 patients/day); b) STD
patients were rare; c) the SA method consumed a
longer time if applied to patients; d) lack of privacy or
special rooms; e) lack of recommended medicines; f )
format of report not consistent with SA; g) there was
a routine antibiotic-injection program in prostitution
areas, hence STD patients did not come to puskesmas;
h) STD patients not too cooperative; i) patients rarely
came for follow up.
For those who used SA, the reasons why they used it
were: a) an STD patient comes in daily; b) SA is practical
To complete interview data, 2 FGDs were carried
out. One was done with 11 doctors and another
with 12 paramedics from different puskesmas in
Malang. Every participating doctor and paramedic
had undergone SA trainings, except for a paramedic
recently positioned in Malang. Generally, the
paramedic considered the training process and
method to be good enough. Regarding the training
duration, several people requested an extension
in order to obtain more detailed explanations.
Contrary to what doctors felt, paramedics
considered the materials to be unclear (they asked:
were the materials direct translations?). Regarding
the teaching method, generally these doctors
felt satisfied with the discussions. But they also
requested that the demonstration tools should be
added, such as pictures of each STD. The video/VCD
produced by Ditjen P2M-PLP was considered only
portraying SA process, and did not show enough
STD cases. With regards to this, they also requested
the video cassette to be multiplied and distributed
to every puskesmas (requested that the video system
should be checked beforehand so that VCD was
compatible). A few doctors asked for the distribution
of the wooden penis model for every puskesmas, to
facilitate the process of IEC on use of condom.
Both doctors and paramedics felt that the training
would be more effective if complemented with
the field practice, and with direct observation and
treatment of STD cases. Pramedics also requested a
standard questionnaire for recording.
In general, participants agreed that the SA method
was quite practical since it did not require waiting
for lab results. Besides that the drugs were already
determined, hence no extra effort was needed.
In practice, the SA method was hard to be applied
since the puskesmas’ medicines were not consistent
with what are suggested in the modules. Not always
can outside prescriptions be used, due to their high
prices.
“The drugs must be on stand-by, must be dropped
at each puskesmas, hence the drugs should wait for
orders, not orders to wait for the drugs.”
311
those who were trained, there were those who were
trained more than once or even become trainers.
The usually-7-day treatment regiment was hard to be
applied. Patients usually were given medicines for 3
days and asked to return for follow up. Often patients
did not return for follow ups. The same also applied
to treatment of the sexual partners: the husband/wife
usually did not want his/her partner to know about the
STD that he/she suffered, while sexual workers found
difficulties in knowing which one of their partners was
ill, let alone asking him/her to consult.
Both doctors and paramedics found it difficult to
apply complete analysis and IEC due to the large
number of patients at the puskesmas (up to 75
patients per doctor). On the other hand, there were
doctors who did not meet or treat their own patients
daily, only received consultations from other doctors
or nurses, if needed. The number of STD patients was
not high: 1-5 per month.
Another main problem in applying SA was the
documentation and reporting. The available systems
were not consistent with SA, because of that until
discussions were held no one had reported the
prevalence of STD based on syndromes. Doctors
complained of confusion in categorizing STD under
LB1, there were genital diseases alone, diseases of
urinary tract, diseases of male genitalia, and disease
of breasts and female genitalia.
“At those puskesmass a lot of documentation already
exists, so it is enough to pass through LB1 alone, a
puskesmas can add the number of items. Diseases of
the genitalia are sufficient when only written as STD
or STD syndromes.”
“At our place, besides LB1 are also registries of genital
diseases, hence it is complete. Thus, when necessities
arise, we don’t have to be confused…it’s already in
that special registry.”
Generally each puskesmas had a laboratory, but some
were active while others were not. From the active
ones, STD tests were rare. Furthermore, with this SA
approach, labs were further non-functional for STD.
As follow up to the training, several doctors asked
that funds be provided to socialize this information
to the puskesmas’s staffs. Besides, to smoothen the
application of SA, it was hoped that big posters
showing the algorithm were provided to every
puskesmas.
312
Conclusions And Suggestions
Conclusions
In general in can be concluded that the materials
and methods of SA training were adequate. Several
suggestions: a) separate training of doctors and
paramedics; training duration for doctors to be
shortened as long as materials were sent earlier, while
for paramedics it may have to be slightly extended;
b) language of modules to be fixed so that they were
easily understandable; c) demonstration models
need to be added; d) consider inserting field practice
as well; e) simplification of algorithms, and printing
these on posters; f ) only selecting those participants
who really handled patients; g) provide a special
instruction for puskesmas with (active) laboratories;
h) provide additional funds for participants, especially
Heads of puskesmas, to spread information on the
training of staff.
The application of SA method was difficult, since:
a) the trained doctors/paramedics did not actually
handled patients (or only received consultations); b)
lack of special rooms for analysis and IEC that were
private in nature and for physical examinations;
c) high number of patients; d) time needed to
handle one patient with STD was quite long; e)
STD patients were rare; f ) since there was a routine
intervention program at some locations or several
doctors/paramedics had frequent clients, hence sex
workers did not come to puskesmas; g) after the
drugs were given, many patients did not return for
follow up; h) non-availability of SA drugs; i) LB1 forms
not accommodating the correct way of reporting
STD; j) treating the sexual partners difficult; k) nonavailability of algorithm posters that can be put up
on walls.
Other vital matters: a) trained doctors/paramedics
did not always pass on their knowledge to their coworkers, thus there were doctors/paramedics who
had never heard of the SA method; b) documentation
of STD or suspected STD diagnoses on medical record
cards was variable, making them hard to compile and
be reported; c) after learning the SA method, labs
tend to be completely inactivate; d) several doctors
who had worked for a long time at the puskesmas
were no longer giving rational therapies.
Complete examination and IEC during SA did not
always need a long time. Several key questions and
materials should always be inquired and conveyed
to patients, such as past disease history, sexual
activity of patients and their sexual partners, method
of drug consumption, and ways to prevent disease
transmission. A clear and concise algorithm poster
can help health workers.
Physical examinations are often skipped at
puskesmas, with the reason being too many patients.
Actually, this phase can be conducted rapidly in
several “rooms” by several assistants (for example 3-4
rooms for 2 doctors, helped by 2 nurses). With the SA
method, physical examination was often mistaken
for being unimportant. Physical examinations
(without speculums) may detect many things, such as
swelling of inguinal glands, genital wounds, herpes,
condilomata, even pregnancy, which otherwise may
not be reported by the patients.
It must not be forgotten that the SA method was
developed to facilitate health care services where no
laboratories existed. At puskesmas that have labs, the
main effort should be aimed at developing that lab’s
ability in detecting STD. Various limitations such as
lack of reagents, overlapping job descriptions of the
workers, etc were of course undeniable. However, a
puskesmas’s work performance must always move
forward with the vision of a health care facility that was
simple but complete. If deemed necessary, treatment
may be given without having to wait for lab results;
but simple lab tests, where available, must always
be attempted for confirmation and documentation
purposes. Gram staining for intracellular diplococcus
and BV (bacterial vaginosis), KOH for fungi, wet slides
for trichomonas, are simple tests that extensively aid
the establishment of a diagnosis.
Several puskesmas have apparently not developed
the habit of spreading information from those who
had undergone training to other co-workers. Periodic
scientific conventions must always be conducted
between the puskesmas’s busy schedules, if we
wish to increase/refresh the medical knowledge of
health workers. This was one way to maintain
professionalism. Besides, refresher trainings for
rational therapy seems needed periodically. An
ineffective treatment will trouble society in the long
run and burden a country financially.
A suggestion for the Indonesian Ministry of Health
would be to continue and develop efforts in providing
drugs consistent with SA. In addition to that, it is
necessary to consider editing the LB1 reporting
format. Correct report of STD diagnoses must be
thought of. A report should be the basis for making
decisions to improve a disease prevention program
(data based policy). Using the current reporting
format, it would be difficult to create a policy for
STD prevention, since STD or suspected STD mixes
with other diseases (example: diseases of breasts
and female genitalia). In an attempt of correcting
this report, the principles of simplicity and minimal
list must be remembered. We naturally do not want
to increase the already-high burden of our friends at
puskesmas.
Reference
1.
Wasserheit J. N. The significance and scope of reproductive
tract infections among third world women. Int. J. Gynecol.
Obstet. 1989, Suppl. 3:145-168.
2.
Moran J. S. Sexually transmitted diseases (STDs). In Wallace
et al. eds., 2nd ed. Health Care of Mothers and Children in
Developing Countries. Oakland, Third Party Publishing Co.;
1995.
3.
Departemen Kesehatan RI, Direktorat Jenderal PPM & PLP.
Penatalaksanaan penderita penyakit menular hendaknya
menjadi dasar dalam membuat keputusan untuk memperbaiki
program penanggulangan suatu penyakit (data-based
policy). Dengan bentuk pelaporan yang berlaku sekarang,
sulit untuk membuat suatu kebijakan penanggulangan
PMS, karena PMS/terduga PMS tercampur dengan penyakit
lain (contoh: penyakit payudara dan alai kelamin wanita).
Dalam upaya memperbaiki peiaporan ini perlu tetap diingat
azas kesederhanaan atau minimalitas. Kita tentu tidak ingin
menambah beban rekanrekan di Puskesmas yang memang
sudah berat itu.
seksual (PMS) dengan pendekatan sindrom: Buku pedoman
interaktif. Jakarta, 1997,
313
Suggestions
The high workloads at puskesmas, which did not
only include examination of patients, caused this
SA method to be difficult to apply. Even so, as the
frontline of public healthcare service, a puskesmas
must always increase its working performance by
showing principles of professionalism. A big room
where many patients enter simultaneously and
has lo facilities for physical examination remains
unacceptable from any medical ethics viewpoint. At
least separation of rooms by simple means such as
curtains could be done.
Evaluation of A Peer Education
Programme for Female Sex Workers
in Bali, Indonesia
K Ford PhD1
D N Wirawan MD MPH2
W Suastina SS2
B D Reed MD MPH3
Muliawan MD MPH2
1
Department of Epidemiology, School of Public Health, University of
Michigan, Ann Arbor, Michigan, USA .
2
Kerti Praja Foundation, Bali, Indonesia.
3
Department of Family Medicine, School of Medicine, University of
Michigan, Ann Arbor, Michigan, USA.
Int J STD AIDS. 2000 Nov;11(11):731-3
Royal Society of Medicine Services
315
Abstract
Summary: The objective of this paper is to evaluate a peer education programme for female sex workers in Bali, Indonesia. Sex workers
participated in face-to-face interviews and STD exams in August± September 1998. In October 1998 one woman from each of 30 clusters
was selected to be a peer educator and received a 2-day training on AIDS, STDs, condom use, and condom negotiation. After training, the peer
educators were visited twice a week by ® eld workers to answer questions and offer support. All sex workers received group education every 2
months. In January± February 1999, the sex workers again participated in face-to-face interviews and examinations. One month after peer
education training, only 50% of the peer educators were still working in the clusters where they were trained. To evaluate the impact of the peer
educators, sex workers in clusters where a peer educator continued to work were compared with sex workers in clusters where women did not
continue to work (n=189). In clusters where women continued to work, there were higher levels of AIDS knowledge (P50.05), STD knowledge
(P50.05) and condom use (82 vs 73%, P=0.15). The prevalence of Neisseria gonorrhoeae infection was also lower in clusters with a peer educator
(39% vs 55%, P=0.05) than in clusters without a peer educator.
Keywords: Gonorrhoea, STD, prostitutes, Indonesia, peer education
Introduction
Methods
Commercial sex has been an important factor in the
spread of HIV/AIDS in Asia. A number of programmes
have been developed to reduce the level of infection
among sex workers and clients including peer
education, group education, counselling, condom
distribution, and STD treatment.1-5
Sex workers participated in STD examinations and
face-to-face interviews in August - September 1998.
In October 1998 one woman from each of 30 clusters
of a brothel complex received a 2-day training on
AIDS, STDs, condom use and condom negotiation.
Following the Health Belief Model6 and social
cognitive theory7, the education programme stresses
the importance of promoting positive beliefs about
disease prevention and condomuse as well as
developing self-efficacy for condom use and condom
negotiation. The programme also included detailed
information about AIDS as well as other STDs. The
importance of recognizing and treating sexually
transmitted infections was emphasized.
Peer education has often been employed as an HIV/
STD prevention model for sex workers. However,
despite its frequent use, few evaluations are
available of its ef® cacy in reducing levels of HIV/STD
infection. The objective of this paper is to evaluate
the effectiveness of a peer education programme for
female sex workers in Bali, Indonesia.
The Bali STD/AIDS study was conducted in several
low-price brothel areas near Denpasar, Bali. Within
these complexes, women work in groups or clusters of
6 - 12 women who are supervised by a pimp. Women
serve an average of 3.8 clients per day. Most of the
women are from East Java and they will typically work
in Bali for a period of time and then return to Java.
The majority (75%) are divorced or separated. Most
(80%) have one or more living children. The children
remain in Java with family members. The women
range in age from 15 - 42 years, mean 27.6. The mean
number of years of schooling was 4.5. Clients of these
women are almost exclusively Indonesian, including
both residents and visitors to Bali.
The peer educators did not present formal educational
programmes to the women in their cluster, but
were present as a resource to them. Women in all
the clusters received group education on the same
topics every 2 months. In January-February 1999 the
sex workers again participated in interviews and STD
exams.
One month after the peer education training, only
50% of the peer educators were still working in the
clusters where they were trained. To assess the impact
of the peer educators, clusters where peer educators
continued to work for at least one month were
compared with clusters where the peer educators
317
Evaluation of A Peer Education
Programme for Female Sex Workers
in Bali, Indonesia
worked for one month or less. Women who were
trained as peer educators were removed from the
data set for the evaluation.
Four measures derived from the interviews and
examinations were used in this evaluation.
(1) AIDS knowledge. AIDS knowledge was measured
as the sum of correct answers to 23 questions. A
list of these questions is shown in Appendix 1.
(2) STD knowledge. STD knowledge was measured
as the sum of correct answers to 12 questions on
STD transmission, symptoms, and treatment. A
list of these questions is shown in Appendix 1.
(3) Condom use. Condom use was measured by the
percentage of each woman’s clients who used a
condom in the last day.
(4) Neisseria gonorrhoeae infection. Cervical mucous
from vaginal exams was tested for the presence
of N. gonorrhoeae (LCx, Abbott Laboratories,
Abbott Park, Illinois, USA). Specimens were
shipped from Bali, Indonesia to the Clinical
Microbiology Laboratories of the University of
Michigan for processing.
Analysis of variance was used to test differences
between groups. This project was approved by the
University of Michigan Health Sciences IRB and the
Kerti Praja IRB.
for women who were in clusters where the peer did
continue working from women who were in clusters
where the peer did not continue working. There was
a small difference in AIDS knowledge, that reached
signi® cance at the 0.09 level.
The evaluation survey showed differences
betweenwomen who were in clusters that included
a peer and women in other clusters. Differences
between AIDS and STD knowledge in the 2 groups
were signi® cant at the 0.05 level. The difference in
condom use between the 2 groups had increased
from 0.2 percentage point to 9 percentage points
(P=0.15). Finally, gonorrhoea infection had decreased
signi® cantly among women working in clusters
with a peer educator (P=0.05). The prevalence of
N. gonorrhoeae was 39% among women with a peer
in the cluster, compared with 55% among women
without a peer in the cluster (P=0.05).
The signi® cance of differences between rounds was
also tested for subgroups of women in clusters with
a peer educator and for women in clusters without
a peer educator. Although there are trends in these
data for women in clusters with a peer educator,
none of the tests on the sub-samples reached signi®
cance at the 0.05 level. The small sample size of the
group with a peer educator may make it dif® cult to ®
nd signi® cant differences.
Results
Table 1 shows the level of AIDS knowledge, STD
knowledge, condom use, and gonorrhoea infection
among sex workers before and after the peer training.
At baseline, the levels of knowledge, condom use
and gonorrhoea infection did not differ signi® cantly
Table 1. AIDS knowledge, STD knowledge, condom use, and
prevalence of Neisseria gonorrhoeae infection among sex
workers at baseline and evaluation
Baseline
AIDS knowledge
STD knowledge
Condom use
N. gonorrhoeae
Peer
No peer
14.5
7.1
74.4
0.53
12.8
6.9
74.2
0.53
N
Evaluation
AIDS knowledge
STD knowledge
Condom use
N. gonorrhoeae
62
N
58
15.1
7.4
82.0
0.39
127
13.4
6.5
73.0
0.55
129
Total
13.4
7.0
74.3
0.53
P value*
0.09
0.61
0.97
1.00
189
13.9
6.7
75.7
0.50
0.05
0.05
0.15
0.05
187
*P value for analysis of variance for differences between peer
and no peer groups
318
Discussion
In this mobile group of sex workers, peer educators
were hard to retain. About half were gone within a
month. However, where the women did continue
to work in a cluster, there were bene® ts in terms of
an increase in AIDS and STD knowledge as well as a
reduction in N. gonorrhoeae infection.
There are 3 limitations to the study. First, the peer
educators were not randomly assigned to clusters.
However, the clusters where the women kept
working did not differ signi® cantly on AIDS/ STD
knowledge, condom use, and gonorrhoea infection
from clusters where women did not keep working
at baseline. Second, measures of condom use
were based on self report and sex workers who are
involved in intervention studies may tend to overreport use. Third, the small sample size of the study
made it to examine subgroup trends. In summary, in
areas where sex workers are very mobile, it may be
hard to retain peer educators.
Acknowledgement: This project was supported by
Grant No. 55942 from the US National Institute of
Mental Health.
Appendix 1: Knowledge And
Selfefficacy Scale Content
AIDS knowledge
(1) Can a person who is already infected with the
AIDS virus appear to be healthy?
(2) Can a person who is already infected with the
AIDS virus but still appears healthy spread the
disease to other people?
(3) Can people catch AIDS by exchanging clothes,
eating from the same dish, or shaking hands
with the person who is already infected with the
virus?
(4) Can an infected woman who is pregnant spread
the AIDS virus to her unborn baby?
(5) Can a person catch AIDS by urinating in the same
place as a person infected with AIDS?
(6) Do some Indonesians already have AIDS?
(7) Can women who work like you become infected
with AIDS?
(8) Can AIDS be prevented by taking medicine/
getting injections regularly?
(9) If a condom is used during sex, can it be used to
prevent AIDS, as long as it does not break?
(10) Can a person who gets AIDS be cured?
(11) Is AIDS spread through:
(a) body sweat
(b) body contact
(c) kissing on the mouth
(d) intercourse without using a condom
(e) injection drug use
(f ) having abortions (equipment)
(g) blood transfusion
(h) injection using used needles
(i) eating contaminated food
(j) mosquito bites
(12) Is AIDS always a fatal disease?
(13) Is there any medication that can prolong the life
of someone with AIDS?
STD knowledge
(1) Can a person who is infected with a sexually
transmitted disease look healthy (without
symptoms)?
(2) If all of your clients wear condoms, can you be
protected against catching these diseases?
(3) Can these diseases be prevented by taking
antibiotics, such as tetracycline, before or after
having sex?
(4) Can sexually transmitted diseases be prevented or
treated by drinking jamu (traditional medicine)?
(5) Can these diseases be prevented by cleaning the
genitals after sex?
(6) Can these diseases be prevented by eating a lot
of vegetables?
(7) Can these diseases be prevented by using a net
when sleeping?
(8) Can these diseases be prevented by not drinking
from the same glass as someone who has an
STD?
(9) Can these diseases be prevented by not changing
sexual partners?
(10)Can these diseases cause sterility/inability to get
pregnant/have children?
(11)If a doctor gives medicine for a sexually
transmitted disease, do you have to continue the
medicine until it is, even if symptoms are gone
beforehand?
(12) Can some of these diseases lead to death?
References
1
Archibald CP, Chan RKW, Wong ML, et al. Evaluation of a safe
sex intervention programme among sex workers in Singapore.
Int J STD AIDS 1994;5:268± 72
2
Laga M, Alary M, Nzila N, et al. Condom promotion, sexually
transmitted diseases treatment, and declining incidence
of HIV-1 infection in female Zairian sex workers. Lancet
1994;344:246± 8
3
Ngugi EN, Plummer FA, Simonsen JN, et al. Prevention of
transmission of human immunode® ciency virus in Africa:
effectiveness of condom promotion and health education
among prostitutes. Lancet 1998;ii:1249
4
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SI, Poskyachinda V. Evaluation of a targeted HIV prevention
programme among female commercial sex workers in the
south of Thailand. Sex Transm Inf 1998;74:54± 8
5
Walter D, Hargono R, Laga M, et al. STD rates over one year
among Indonesian sex workers exposed in different degrees
to a peer health education programme in Surabaya (Abstract
650/PTCD058). 5th International Congress on AIDS in Asia and
the Paci® c. Kuala Lumpur, October 1999
6
Rosenstock I, Strecher V, Becker M. The health belief model
and HIV risk behavior change. In: DiClemente RJ, Peterson
JL, eds. Preventing AIDS: Theories and Methods of Behavioral
Interventions. New York: Plenum, 1994:5± 24
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Bandura A. Perceived self ef® cacy in the exercise of control
over AIDS infection. In: Mays VW, Albee GW, Schneider SF,
eds. Primary Prevention of AIDS: Psychological Approaches.
London: Sage, 1989:128± 41
319
However, where they are retained, they may be
helpful in increasing AIDS and STD knowledge and
promoting preventive behaviours amongst sex
workers.
Translated from Strategi Pengendalian Infeksi Menular Seksual pada Perempuan dengan Cara Pendekaan Sindrom
(Sebuah Tinjauan).
1
Communicable Disease Research Center, National Institute of Health
Research & Development, Jakarta, Indonesia.
Majalah Obstet Ginekol Indones. 2002 Apr;26(2):82-91
Perkumpulan Obstetri Dan Ginekologi Indonesia
321
Strategy for Control of Sexually Transmitted
Infections Using The Syndromic Approach
among Women: A Review
Abstract
Sexually Transmitted Infections (STI) still constitute a major community health problem in many countries in the world. In Indonesia, Health
Centers and Hospitals have been reporting 5,000 - 10,000 syphilis and 20,000 - 50,000 gonorrhoea cases yearly. The syphilis and gonorhoea
prevalence were found to be less than one percent among women with low risks to get STI, while chiamydia was found at higher rate, i.e., above
4%. High risk women had higher prevalences: gonorrhoea 10-20%, chlamydia 20-40%, and syphilis 2-10%. Since STI has an important role in
the transmission of HIV the current situation of the HIV/AIDS epidemic has created a growing concern about STI. Effective early treatment is a
crucial component in STI and HIV/ADS control programs, This article presents the summary of some international and national research on the
advantages and disadvantages of syndromic approach for STI management, a method widely encouraged by the World Health Organization. It is
concluded that with syndromic approach, women with vaginal discharge are to be treated for vaginitis only, Treatment for cervicitis (gonorrhoea/
chlamydia) based on syndromic approach had a very low positive predictive value, hence was not recommended. Treatment for both vaginitis and
cervicitis is only recommended to be given to women who come with vaginal discharge, who are known to have high prevalence in gonorrhoea/
chlamydia, for examples sex workers.
llndones J Obstet Gynecol 2002; 26-2: 82-911
Keywords: Sexually Transmitted Infection, syndromic approach, cervicitis, vaginitis.
Introduction
Sexually Transmitted Infections (STI – formerly STD)
continue to be a major health problem for the world,
including Indonesia. It is estimated that incidence
of certain STI (syphilis, gonorrhea, Chlamydia,
and trichomoniasis) in this world is at 329 million
cases per year.1 Meanwhile WHO WPRO (Western
Pacific Regional Office) estimated the prevalence
of Chlamydia in Western Pacific countries to be 1
– 20%, gonorrhea 1 – 4%, and syphilis 1 – 8%).2 In
Indonesia, every year primary health care centers
(or puskesmas) and hospitals report between 5 and
10 thousand syphilis cases and 20 to 50 thousand
gonorrhea cases.3 This number is the minimum value,
remembering that most STI patients prefer to visit
private general practitioners.4 From several surveys,
the prevalence of syphilis and gonorrhea obtained
among low risk women were <1%, and Chlamydia
generally above 4%.3 Whereas among female sex
workers, prevalence of gonorrhea generally was 1020%, Chlamydia 20-40%, and syphilis 2-10%.3
The endemic level if STI in a country, besides
determined by demographical, cultural, socioeconomical, and sexual behavioral factors of its
society, is also influenced by the availability of
effective healthcare facilities (such as: trained
health workers, adequate diagnostic facilities, and
availability of correct and accessible antimicrobials).5
The appearance of HIV/AIDS epidemic in the world
– where HIV infection may be categorized under
STI – increased the problem of STI. Many studies
showed that early diagnosis and correct treatment
for other STI significantly influenced the decrease
of HIV transmission.6 Due to this, early and effective
STI treatment is considered one vital component of
HIV and STI prevention and control programs. On
an individual level, early diagnosis and immediate
effective treatment of STI will prevent occurrence
of complications; while at a population level, this
strategy will reduce the transmission of HIV.
Treatment of STI
Ideally, STI treatment is based on results of laboratory
tests to specifically recognize the causative agent.
This method is named the etiological approach.
Unfortunately it is quite expensive. Its costs include
provision of infrastructure and maintenance of
labs, along with purchasing supplemental tests. In
developing countries, superior labs are difficult to
find at basic health care facilities. If present, they are
often unaccompanied by quality-control procedures
to ensure validation of tests.5 On the other hand,
323
Strategy for Control of Sexually Transmitted
Infections Using The Syndromic Approach
among Women: A Review
even in developed countries, where facilities and
funding are not a problem, etiological treatment for
STI are also rarely conducted. For example, these are
only done for patients found through screenings for
Chlamydia trachomatis or Neisseria gonorrhoeae.7
This is because the etiological approach which
uses lab tests consumes much time, thus delaying
diagnosis and treatment, that may enable patients
to continue transmitting their infections to others, or
worsening complications for themselves.
Another STI treatment which is more widely
accepted in the world is the presumptive approach.
With this method patients are not asked to return for
obtaining final diagnoses, but immediately treated
on the spot based on the presumed diagnosis. What
is still debated about this is the criteria used to give
the treatments (similar to a net, and how big must
the holes be).7 According to Steen and Dallabetta,
there exists two forms of controversial presumptive
approaches: mass/collective treatments and
syndrome approach.8 Mass treatments, which do not
pay attention to individual clinical manifestations at
all, are only effective for endemic chronic infections;
while their capabilities are doubted to control short
durational acute infections such as gonorrhea.7,9
The mass approach is also difficult to apply to
a population with rapid migrations, since the
possibility of repeated infection is high. Populations
with high risks of acquiring STI are often shifting.
To cover for the weaknesses of the etiological and
mass/collective approaches, WHO has developed
and promoted STI treatment by the syndromic
approach.10
Syndromic Approach to Treat STI
The basis of the syndromic approach to treat
STI is the relatively constant observation of a
number of signs and symptoms, knowledge on
microorganisms that frequently cause these
syndromes, and knowledge on antimicrobials that
can kill those microorganisms.11 The algorithms
to formalize these procedures was developed as
guide for medical workers for treatment. The entry
point of each algorithm is a sign or symptom, such
as urethral discharge, vaginal discharge, or genital
ulcers. Socio-demographical and behavioral data
may be used in an attempt to increase detection of
infections.5 And according to the basis of syndromic
approach, medicines dispensed will treat many
324
possible microorganisms causing that syndrome.5,11
Validity of the algorithms for treatment depends
on their sensitivity, specificity, positive predictive
values (PPV), and negative predictive values (NPV).
Sensitivity relates to that method’s capability to
recognize the condition/disease, while specificity
is the capability to recognize those who do not
have the sought condition/disease. The higher the
sensitivity the fewer the missed cases, and the higher
the specificity the fewer the false positive cases. PPV
is the measurement of how many people diagnosed
with the sought disease are actually suffering from
that disease, while NPV shows how many of them
marked as negative truly do not have that disease.11
Sensitivity and specificity are basic qualities of an
algorithm or method, while PPV and NPV depend
on the prevalence of that condition/disease in a
population. Hence, though a method has good
sensitivity and specificity (>90%), if applied to a
population with low STI prevalence, the PPV would
still be low.11 Simple lab tests may be inserted into
the algorithm, as an effort to increase its specificity. In
order to increase the sought disease’s prevalence or
PPV, risk factors are inserted into the algorithm.5,11 Risk
factors used by the WHO are (a) have symptomatic
partners, (b) <21 years old, (c) not married yet, (d)
have >1 sexual partners, (e) have new sex partners
within the past 3 months.
From society’s viewpoint, priority is usually given to
methods possessing high sensitivity, even though
with low specificity, in order to provide as many
adequate treatment to as many cases as possible.
However, for a successful program, the efficacy will
slowly decrease (PPV will decline). This is solely due
to the decline in the disease’s prevalence caused
by the program’s success. This is the importance of
evaluating a program periodically, in order to make
adjustments accordingly.
The advantages of the syndromic approach are:
speed up treatment, providing treatment on the
first visit hence breaking the transmission chain of
STI (and possibly HIV), preventing STI complications,
low-cost since labs are not used, and increasing
satisfaction of patients.5 However the syndromic
approach’s main and unavoidable weakness is
over treatment. The number of false positive cases
(treated but not ill) depends on the value of PPV.
The disadvantages of over treatment are: spending
Another important matter to be considered is
that the Syndromic Approach is not intended to
deal with subclinical or asymptomatic STI cases
(symptoms being, not specific, or not present at all),
or those treating the STI by oneself.5 In other words,
the syndromic approach can only be used for STI
patients with clear signs and symptoms, who visit
medical facilities. Consequently, there needs to be
programs that support the Syndromic Approach,
such as: (a) mass or social counseling (or penyuluhan)
to society so that they may recognize STI symptoms,
immediately visit medical centers, and refrain
from treating themselves; (b) increasing society’s
access to STI treatment centers; and (c) treating STI
patients’ partners (by presumption, without prior
examinations).5
Application of Syndromic Approach to
Women
Lower abdominal pain and adnexal pain syndrome
Frequent lower abdominal pain – along with adnexal
pain and cervical pain on movement – is the most
frequent symptom suffered by women with Pelvic
Inflammatory Disease (PID).12 Causes of PID are
generally multiple; though among 60% cases the
gonococcal or Chlamydial germ can be isolated.13
Even so, lower abdominal pain syndrome is neither
sensitive nor specific for PID. Other conditions that
may also cause the same symptom are ectopic
pregnancy, appendicitis, hemorrhagic ovarian cyst,
or endometritis. Even 6-45% patients with this
syndrome turn out to be normal, not suffering from
any disorders.5 Examinations to definitively diagnose
PID include laparoscopy, endometrial biopsy, a
tomography where all of these must be done at
hospitals with complete infrasturcture.5
Fast and correct PID treatment is needed, since its
complications include infertility, ectopic pregnancy,
and chronic pain.12 Due to this, the guide used to treat
PID is high suspicion and low-threshold diagnostic
determination.14 This choice is taken though it is
realized that many cases will occur who receive too
many drugs. Three diagnostic criteria recommended
are (a) lower abdominal pain, (b) adnexal pain, and
(c) cervical pain on movement.14
In the Syndromic Approach for PID, the sign and
symptom of lower abdominal pain are treated
with therapy against gonococcal, Chlamydial, and
anaerobic bacteria.15 Even so, a study by Ryan et
al16 in Morocco showed that lower abdominal
pain, adnexal pain, and uterus pain are often over
interpreted, so as to not be specific for gonococcal or
chlamydial infections. Besides that, a low PPV caused
this method to be less beneficial for treating lower
abdominal pain in Morocco.
Vaginal discharge syndrome
Syndrome of vaginal discharge (which is abnormal)
may be manifestation of vaginal inflammation
(vaginitis), but also of cervical inflammation
(cervisitis). Diagnosis of cervicitis is very hard to do
since many cases are asymptomatic, clinical signs
being less sensitive and less specific (to differentiate
vaginitis from cervicitis), specimen collections are
relatively difficult, and tests are expensive and have
variable sensitivity/specificity.5 In places where
STI prevalence is high, several cases of vaginal
discharge are caused by cervicitis due to gonorrhea
or Chlamydia. Both of these infections are considered
important since they may cause severe complications.
On the other hand, many etiologies of vaginitis are
trichomoniasis or bacterial vaginosis (BV).5 Both may
cause premature births in pregnant women and
facilitate the transmission HIV; besides, BV is also a
risk factor of PID.17
WHO’s main objective for developing the algorithm
for vaginal discharge syndrome15 is to facilitate
treatment of women who present with vaginal
discharge as vaginal discharge or most commonly
called keputihan (fluor albus) in Indonesia. It is
assumed that at places with limited resources,
dealing with cases of vaginal discharge is not optimal,
seems disorganized, - and most importantly – missed
out on treatment of gonococcal and chlamydial
infections. Based on these facts, the Syndromic
Approach guidelines for STI recommend that the
vaginal discharge syndrome is treated with therapy
for trichomoniasis and BV, as well as gonorrhea and
Chlamydia.15 Treatment for candida is also added
though the complications of this fungal infection is
less severe.
Several simple lab tests that can aid treatment of
vaginal discharge are wet slides for trichomoniasis
325
more funds on medicines, side effects of drugs and
microbial resistances, disturbing normal genital flora,
social stigma, and domestic violence.5,11
(sensitivity 38-92%, specificity 100%);5 pH test,
amine test, detection of clue cells for BV; Gram
staining for gonococci (sensitivity 40-65%, specificity
up to 97%).5 Besides, the increase in number of
polymorphonuclear (PMN) leucocytes on Gram
staining of cervical discharge, easily hemorrhagic
cervix, and cervical edema can help determine
diagnosis of cervicitis.
The application of Syndromic Approach to treat
cases of vaginal discharge until now is still being
debated; especially since this method has been
frequently applied to women who do not come
with spontaneous complaints. Many studies have
been done to estimate the validity of the Syndromic
Approach for both of these inflammations; for both
the population of women with high STI prevalence
such as sex workers, and population of low prevalence
such as mothers who visit antenatal or birth control
clinics. In those studies, comparison was made with
lab testing as the gold standard. Several combinations
of algorithms were used, which included assessment
of risks, physical examinations, and simple lab tests.
Validation of Syndromic Approach
Among women with genital complaints
Many studies only focussed on the validity of
Syndromic Approach for infections with gonococci
or Chlamydia, only a few have attempted to assess
its validity for vaginal infections. What is meant by
vaginal infections are Trichomonas vaginalis, BV, and
vulvovaginal candidiasis; the latter two are still under
Reproductive Tract Infections (RTI).
Behets et al’s research in Jamaica, as reported by
Dallabetta et al5, took place at an STI clinic in a
city where the prevalence of gonococcal and/or
Chlamydial cervical infection was 35%. The common
STI treatment procedures in Jamaica at that time
were treating every patient with vaginal and cervical
discharge. In this study it was portrayed that this
local standard method had sensitivity of 73% and
PPV of 43%. Whereas WHO’s Syndromic Approach
was slightly better; sensitivity of 85%, specificity of
40%, and PPV 43%.5
In Malawi, Costello Daly et al18 tried widening the
inclusion criteria with various additional complaints
(besides vaginal discharge) such as pain during
urination, lower abdominal pain, pain during sexual
intercourse, swelling or itchiness around the vagina,
326
swelling of inguinal glands, and smelly discharge.
Risk assessment was also modified in age and disease
history, and additional physical examinations were
inserted: bimanual palpation (fingers in the vagina)
and speculum examination. In fact, amongst women
with cervicitis prevalence of 19,5%, the algorithm
without bimanual and speculum examination
produced sensitivity of 68% and PPV of 31%. By
adding bimanual examination a slightly higher
sensitivity was obtained, a slightly lower specificity,
and slightly higher PPV (33%). Adding the speculum
exam didn’t improve those results.18
A study in Seattle, Washington, by Ryan et al19 once
again showed that applying limited Syndromic
approach to vaginal discharge decreased the
accuracy of the results. This study also added other
complaints such as itchiness, swelling, etc. Almost
every complaint was associated with vaginitis
(trichomoniasis/BV/candidiasis), and not all with
cervicitis. One main finding was that vaginal
discharge as the chief complaint can not be used to
estimate the presence of cervicitis due to gonorrhea
or Chlamydia. Among the women with cervicitis
prevalence with 24%, the algorithm that only
consisted of symptoms (complaints and risk factors)
had sensitivity/specificity/PPV of 68/53/32%. The
results didn’t improve after the algorithm was added
with bimanual and speculum examinations. By
adding microscopic examination (PMN count), the
validity became 82/41/31%. The modified algorithm,
added with bimanual, speculum, and microscopic
examinations can improve PPV (58/82/51%). 19
Ryan et al’s19 study above found that complaint
of vaginal discharge is good enough to estimate
the presence of trichomoniasis or BV, but not for
candidiasis. Within the patient group with vaginitis
prevalence of 42%, sensitivity/specificity/PPV values
obtained were 68/50/50%. Addition of speculum
and microscopic examination would reduce the
sensitivity value to a third, but increase PPV to 78%.
In Tanzania a study by Mayaud et al to validate WHO’s
algorithm was done at a STI clinic, where cervicitis
prevalence was 11.4%.20 The sensitivity/specificity/
PPV values were 62/64/18%, meaning that algorithm
missed detecting 38% infected women.
Ryan et al’s16 study in Morocco done to a group
of women with vaginal discharge (prevalence of
cervicitis due to gonorrhea/Chlamydia 8,8% and
Alary et al21 in Benin again showed that WHO’s
algorithm applied to a group of women with genital
symptoms (cervicitis prevalence 7,8%) had almost
equal validity values, i.e. sensitivity/specificity/PPV of
87/42/11%. The addition of pelvic examination only
increased the sensitivity value a little, but did not
change the PPV.
In Indonesia, HIV/AIDS and STI Prevention and Care
Project22 also checked women who came to STI
clinics complaining of vaginal discharge (prevalence
of cervicitis due gonorrhea/Chlamydia at 14%). The
application of WHO’s algorithm produced sensitivity/
specificity/PPV of 95/16/24%. Adding speculum
exam slightly decreased the sensitivity and increased
PPV. Whereas adding simple lab tests (PMN count)
also only increased PPV to 27%. In this same study,
the Syndromic Approach were conducted on visitors
of obstetric-gynecology clinics presenting with
vaginal discharges (prevalence of cervicitis due to
gonorrhea/Chlamydia 7%) with results of 62/44/7%.
The speculum exam only slightly increased tbe
sensitivity but didn’t change PPV. Adding simple lab
tests increased sensitivity until 70%, but PPV only
raised to 8%.22
Summary
The application of Syndromic Approach on a group
of women with complaints of vaginal discharge with
prevalence of cervicitis due to gonorrhea/Chlamydia
being 7-35% gave the following results: 1) WHO’s
algorithm generally needs to be modified with
additional complaints, risk factors, and examinations
in accordance with the local situation; 2) sensitivity
values were generally high (61-95%, with an average
value 74%); 3) PPV were generally low with a wide
range (7-43%, averagely 24%); this was due to the low
prevalence of cervicitis; 4) this low PPV indicated quite
many cases which were over treated; 5) generally PPV
values weren’t far above the prevalence of cervicitis
due to gonorrhea/Chlamydia (averagely higher by
6%), meaning treatment using Syndromic Approach
was only a bit better that randomly prescribing
medicines; 7) addition of bimanual and speculum
exams generally only slightly improved validity
scores; 8) simple lab tests added to the risk factors
and pelvic exams also only slightly improved validity
scores.
Application of Syndromic Approach on a group
of women with vaginal discharge complaints and
prevalence of vaginitis (trichomoniasis/BV) between
30-47% gave these results: 1) sensitivity were
generally high (68-98%); 2) PPV was also high due
to the high vaginitis prevalence (usually >50%); 3)
addition of speculum exam didn’t improve validity
scores.
Towards Attenders of Birth Control
Clinics (As Screening Efforts)
It has been long known that cervical infection
(cervicitis) more often happens without any signs or
symptoms. By this, if STI treatment is only conducted
on women who come with complaints, thus it is
estimated that many cases of STI will be missed from
treatedment. Because of this, to expand the area of
STI treatment, Syndromic Approach was also tried as
a screening effort amongst women who come with
other intentions or complaints, such as at Mother
and Child Health clinic, birth control clinics. This
group is generally considered low-risk behavior, thus
prevalence of STI is expected to be low. In reality, STI
prevalence in this group is quite high.22,23-28
Indonesia HIV/AIDS & STD Prevention Care Project22
attempted to screen women who came to mother &
child clinics in Bali, and maternity/pregnancy clinic at
Makassar. Prevalence of cervicitis due to gonorrhea/
Chlamydia within these two groups were 5 and 9%,
while the prevalence of vaginitis (trichomoniasis)
was 2 (and 1%). Actually risk factors and clinical
manifestations of cervicitis produced sensitivity/
specificity/PPV of 44/74/11%. Risk factor and clinical
signs of vaginitis gave a much higher sensitivity
62/44/7%. The combination of clinical manifestations
of cervicitis, vaginitis, risk factor and addition of
simple lab test, as Gram stain gave maximal results:
73/35/8%.
Thomas at al23 conducted screening of pregnant
women who came to mother & child clinics in
Nairobi, Kenya. It was found that the prevalence of
327
prevalence of vaginitis by trichomonas/BV 30,1%).
For cervicitis, WHO’s already modified algorithm was
added with speculum and bimanual examinations,
produced sensitivity 61-86%, specificity 42-43%,
and PPV 9-10% (only a little higher than its cervicitis
prevalence). Whereas for vaginitis, the risk factor
approach added with bimanual and speculum exam
produced sensitivity 91-98%, specificity 7-12%, and
PPV 27-33%.16
cervical infection was 11% and vaginal infection
(trichomoniasis/ candidiasis/BV) was 54%. Validation
of WHO’s algorithm on cervicitis produced sensitivity/
specificity/PPV of 50/79/12%. Besides, it was also
found that vaginal discharge and LED-positive
tests were not good predictors for the existence of
cervicitis, but more predictive of vaginitis.
In the Population Council’s publication on Operations
Research Summaries24, it published the results of
research on Reproductive Tract Infections (RTI) among
visitors of family planning and mother & child clinics
in Nakuru, Kenya. It was found that the prevalence
of cervicitis (gonococcal/Chlamydia) was 7,5% and
94,4%, and prevalence of vaginitis (trichomoniasis,
candidiasis, and BV) was 47 and 56%. Application of
Syndromic Approach to screen RTI had low sensitivity:
5% at family planning clinics and 16% at mother &
child clinics. PPV for cervicitis was only 11% and 8%,
while for vaginitis PPV was 61% and 70%.
In Indonesia, Iskandar et al25 evaluated methods
of diagnosing endocervicitis at family planning
clinics in Northern Jakarta. Prevalence of cervicitis
(gonococcal/Chlamydia)
within
the
studied
population was 10%. Diagnosing clinical cervicitis
had sensitivity/specificity/PPV of 49/75/18%. Gram
staining tests for gonorrhea (prevalence: 1,2%) was
83% sensitive, 95% specific, and had PPV of 16%.
Bourgeois et al26 conducted screening on pregnant
mothers who visited public healthcare centers
in Liberville, Gabon, for antenatal check-ups. On
a population with cervicitis prevalence of 11%,
the modified Sydromic Approach had sensitivity/
specificity/PPV of 73/77/17%. These values are
not that different when examinations were done
by doctors or midwives. For vaginitis (prevalence
of trichomoniasis/candidiasis 40%), the values of
validity were 8/89/32%.
Summary of screening on visitors of
family planning and mother & child
clinics
Applying the Syndromic Approach as a screening
attempt of cervicitis on attenders of family planning
and mother & child clinics with cervicitis prevalence
(gonococcal/Chlamydia) of 5-14% generally gave
the following results: 1) sensitivity were commonly
below 50%, which meant that more than half of STI
cases were not detected; 2) specificity were generally
328
above 74%, which meant that this method is quite
capable of separating the healthy ones; 3) PPV were
commonly only a little bit higher than prevalence
of cervicitis (not reaching twice the prevalence),
meaning that it was only slightly better than random
treatment; 4) efforts to modify the Syndromic
Approach by adding simple lab tests seemed to
only induce a slightly better result; 5) Gram staining
(Gram-negative diplococci) seemed valid enough to
predict existence of gonococcal cervicitis. Applying
the Syndromic Approach for screening vaginitis
on attenders of family planning and mother &
child clinics with vaginitis prevalence of 1% (just
trichomoniasis) to 56% (trichomoniasis/candidiasis/
BV) gave the following results: 1) sensitivity wasn’t
consistent, sometimes above and sometimes below
50%; 2) specificity wasn’t consistent, sometimes high
and sometimes low; 3) PPV was more often a bit
higher that the disease’s prevalence (not reaching
twice the value).
Attempt to screen Female Sex Workers
Indonesia HIV/AIDS & STD Prevention and Care
Project22 also screened female sex workers in
Kupang. Prevalence of gonococcal/chlamydial
cervicitis among them was 44%, while vaginitis
prevalence (trichomoniasis) was 24%. In fact clinical
signs of cervicitis had sensitivity/specificity/PPV of
46/64/50%, while clinical signs of vaginitis to treat
gonococcall/chlamydial cervicitis gave a much
higher PPV value: 38/80/75%. The combination of
cervicitis and vaginitis clinical signs and risk factors,
and adding simple lab tests (Gram’s stain), gave
maximum results: 78/35/48%.
Sedyaningsih et al27 screened female sex workers in
East Java and North Sulawesi. Prevalence of cervicitis
(gonococcal/Chlamydia) on these two groups
were 44% and 37%, and vaginitis (trichomoniasis/
candidiasis/BV) were 24% and 43%. Validation of
the Syndromic approach for cervicitis produced
sensitivity/specificity/PPV of 31/83/59% for group I
and 49/56/40% for group II; for vaginitis 35/80/35%
for group I and 54/60/50% for group II; for cervicitis/
vaginitis 33/87/74% for group I and 48/57/64% for
group II (prevalence of cervicitis/vaginitis being 53%
and 61%).
In Abidjan, Ivory Coast, Diallo et al28 tried developing
and comparing several algorithms for diagnosing
cervicitis among a group of sex workers with the
Since their occupation was to offer sex, which meant
having a clear risk factor, the assessment of risk factor
in the Syndromic Approach’s usual algorithm can
no longer be used for sex workers. Other risk factors
suitable with this occupation needs to be found, such
as period of occupation, tariff, number of clients,
usage of condoms, and so on. Remembering that the
main objective of applying Syndromic Method on
this group was to break the transmission chain of STI,
there is need to find combinations of risk factors, signs,
symptoms, and lab tests which have high sensitivity.
Summary of screening of female sexual workers
Application of Syndromic Approach on female sex
workers for screening when prevalence of cervicitis
(gonococcal/chlamydia) was between 24-44% and
vaginitis between 24% (just trichomoniasis) to 43%
(trichomoniasis/BV/candidiasis) gave the following
results: 1) sensitivity for cervicitis generally was
unsatisfactory (<50%). But if all risk factors, clinical
signs of vaginitis/cervisitis/PID, and PMN lab counts
were united, sensitivity may reach 78-79%; 2) PPV for
cervicitis with any indicator generally did not reach
twice the prevalence of gonorrhea/Chlamydia, and
ranged at 40-67%; 3) Sensitivity of vaginitis wasn’t
consistent (some were above and some below 50%),
with PPV being only a little higher than its vaginitis
prevalence; 4) risk factors for sex workers should be
adjusted with their occupation.
Conclusion
Based on the analysis of the study results above, it
can be concluded that prevalence of RTI –including
STI – among women who are considered low-risk
was in fact not always low. This was found in several
countries, including Indonesia. Secondly, treatment
of cervicitis (gonococcal/Chlamydia) based on the
Syndromic Approach for women who complained
of vaginal discharge (spontaneous or by history)
was actually sensitive enough, however due to the
low PPV – only a little higher than the prevalence of
cervicitis due to gonorrhea/Chlamydia – treatment
for cervicitis based on Syndromic Approach is
generally not recommended. On the other hand,
treatment of vaginitis for women with complaints of
vaginal discharge is sensitive and specific enough;
thus this method is recommended for use (especially
for trichomoniasis and BV). However, only on groups
of women who complain of vaginal discharge that
are known to have high prevalence of cervicitis
of gonorrhea/Chlamydia (such as female sex
workers) is this treatment of cervicitis and vaginitis
recommended.
The Syndromic Approach is not recommended for
screening STI amongst low-risk women due to its
low sensitivity and PPV. The modified Syndromic
Approach consisting of adjusted risk factors, clinical
signs of cervicitis/ vaginitis/PID, and leukocytecounting lab tests on vaginal and cervical swabs,
can be used to screen for STI amongst female sex
workers. The method above is being used despite
realizing that many cases may be overtreated.
Implications For STI Programs
In Indonesia
Currently, in several big cities in several provinces,
programs for periodic STI examinations of female
sex workers are being implemented. These screening
programs are using the Syndromic Approach and
are an active search for STI. These examinations
may or may not use speculuma. Simple lab tests are
commonly not conducted.
These programs implemented for high-risk women
– with prevalence of gonorrhea or Chlamydia
commonly ranging at 20-50% and RTI at 50-60%
– need to reduce expenditure, which is around Rp
15.000 – 25.000 per one correctly-treated case.30 But
it must be realized that with this method, more than
329
prevalence of cervicitis (gonococcal/Chlamydia)
being 35%. The Syndromic Approach which only
consisted of discharges and findings of mucopurulent
discharge in the endocervix had sensitivity/specificity/
PPV of 18/95/67%. The Syndromic Approach which
combined sociodemographic and behavioral factors,
clinical signs of cervicitis/vaginitis/PID, and simple lab
tests (PMN counts) can improve the validity values
to 79/54/48%. Wheras in Dakar, Senegal, Ndoye et
al29 studied the validity of several STI indicators on
a group of sex workers with prevalence of cervicitis
(gonococcal/Chlamydia) being 25%. They concluded
that not one indicator (young age, vaginal discharge,
mucopus in endocervix, LED-positive urine, 10 or
more leucocytes on slides of vaginal/cervical swab)
had a satisfactory validity value. Meaning, that not
one of them simultaneously had sensitivity of >50%
and PPV above the studied prevalence. The one
closest to this requirement was the presence of 10
or more leucocytes within the preparation of cervical
swab with Gram staining, which was 66/64/38%.
50% of female sex workers with STI will be missed,
whilst quite many of them will be over treated. This
latter problem may not be too worrying, but the first
problem will reduce the effectiveness of this program.
The goal of breaking chain of STI transmission will not
be reached. Although the weaknesses above seem to
be corrected by using periodic examinations, these
Periodic Examinations can be further improved with
the suggestions in the subsequent chapter.
Certain provinces conduct pilot projects of integrated
STI services at mother & child clinics, family planning,
primary health care centers (puskesmas), and
hospitals. They use Syndromic Approach, with or
without speculum, and is commonly without simple
lab tests. Remembering that the targeted group is
low-risk women with prevalence of RTI being 5-15%,
thus based on previous studies, this program will
have many weaknesses. Besides being expensive –
Rp. 45.000 – Rp.180.000 per correctly treated case30
– this program also has potential to induce social
stigma and unnecessary domestic brawls, since
more than 75% treated women do not in fact have
an STI. In addition to that the aim of breaking STI
transmission chain can not be achieved since more
than 50% women who truly have STI are not detected
(see recommendations below).
Recommendations
Currently, constructive strategies state that every
policy is evidence based, meaning that strategies
are based on information gained from a process of
systematic and structured data search. Based on
the assessments above, the Syndromic Approach is
recommended for used in the following situations: a)
Female patients with lower abdominal pains along
with other PID symptoms (adnexal pain and cervix
pain on movement), despite realizing that many
cases may be overtreated; b) female patients with
vaginal discharge to be treated as vaginitis caused
by trichomoniasis, BV, and candida. If patients report
back (when the medicines are finished) and the
vaginal discharge persists, then it should be treated
as gonococcal and chlamydial cervicitis; c) female
patients with known high risks, with complaints of
lower abdominal pain and vaginal discharge, should
be immediately treated as vaginitis and cervicitis.
For screening, the Syndromic Approach is not
recommended to be applied on family planning and
mother & child clinics, but can be applied to high-
330
risk women with the following terms: a) assessment
of risk factors should be modified; b) use all signs
and symptoms of vaginitis, cervicitis, and PID; c)
add simple lab tests: leukocyte count in cervical and
vaginal swabs.
Other than that, the Syndromic Approach can not
be used on its own, it must be supported by other
programs such as: a) mass/collective counseling
(penyuluhan) for recognition of STI signs-symptoms,
and recommendation to immediately visit the health
facility and not treating one’s self; b) promotion
of using condoms 100% in certain areas by paying
attention to the society’s sensitivity; c) improve
facilities of STI services – including diagnostic labs
– and society’s access to these; d) treatment of
patients’ sexual partners presumptively (without
examination).
Other studies that need to be conducted in Indonesia
include research on obtaining valid risk factors to
be used in assessing risks of female sex workers.
Combinations of risk factors, signs, symptoms, and
lab tests need to be established, which have high
sensitivity and PPV values. In addition, studies for
obtaining simple lab tests (rapid, easy, cheap) for
diagnosis of Chlamydia and genital ulcer agents,
as well as periodic quality control of diagnostic
methods, are also needed.
Special Thanks
The writer thanks the Indonesia HIV/AIDS and STD
Prevention and Care Project (funded by AusAID)
and the National AIDS-Tackling Committee which
sponsored this review of Syndromic Approach
strategy, and for the permission given to publish
this article. Special gratitude for Penny Miller and
Tim McKay from the above project, who have helped
review this article.
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331
an Peran dan Tanggung Jawab Laki-laki dalam Upaya
Menghambat Epidemi HIV/AIDS di Indonesia’ Departemen
Kesehatan dan Kesejahteraan Sosial, Jakarta 25 Januari 2001.
The Current Situation of the HIV/AIDS
Epidemic in Indonesia
Pandu Riono1
Saiful Jazant2
1
The Action for Stop AIDS Programme, Family Health International-Indonesia.
2
Subdirectorate of AIDS and STDs, Directorate of Communicable Disease
Control and Environmental Health, Ministry of Health, Republic of Indonesia.
AIDS Educ Prev. 2004 Jun;16(3 Suppl A):78-90
333
Abstract
Until 1999 the known prevalence of HIV in Indonesia was low, except for isolated geographic groups exposed to Thai fisherman. Since then,
the prevalence among injection drug users in rehabilitation centers in Jakarta has risen rapidly to approximately 45-48%, according to
surveys in 2001. By 2002 the prevalence had risen to 8-17% among female sex workers, 22% among transvestite sex workers, and 4% among
other male sex workers. Condom use is low in all groups, and there is considerable sexual mixing between risk groups. Surveys suggest that
an increasing proportion of adolescents use drugs and have had sexual intercourse. Thus, although the epidemic in Indonesia is currently in
the WorldHealthOrganization-defined “concentrated stage,” all the ingredients for rapid spread are present. Intensive effective intervention
strategies—condom use and clean needle use promotions—need to be implemented, especially in the high-risk groups, if a more serious
epidemic is to be averted.
The HIV epidemic in some areas in Indonesia has
already reached the “concentrated” stage. The
prevalence of HIV in a number of risk sentinel groups
(female and transvestite sex workers, injection drug
users [IDUs]), and prisoners) has exceeded5%but has
not yet reached 1% in pregnant women who visit
antenatal care services.
It is important to realize that in this epidemic the
overlapping behavioral risks allow HIV to spread
from one person to another within different risk
groups. The further spread of the epidemic depends
on behavioral risk channels between different risk
groups and whether the infection is spread to their
sexual partners. The highest increases have occurred
among IDUs during the last 5 years. HIV can spread
from them to other groups through sexual intercourse
(Center for Health Research, University of Indonesia,
& Ministry of Health, 2002a, 2002b; Central Bureau of
Statistics & Ministry of Health, 2003).
The strengthened and intensified HIV sentinel
surveillance system in Indonesia, as well as information
from related studies, provide a better picture of the
progress of the HIV epidemic in Indonesia to date. There
is a need to stop the further spread of the HIV epidemic
by intensifying HIV prevention efforts in Indonesia,
through reducing both the sharing of contaminated
needles among IDUs and sexual risk behaviors.
In this article, we present the trends of the HIV/AIDS
epidemic in Indonesia and HIV prevention activities
to slow the rapid spread of HIV infection throughout
the country.
Estimation Of The Number Of People
Vulnerable To HIV Infection And
Number Of People With HIV In Indonesia
It was estimated that as of 2002 there were
approximately 12 million to 19 million people in
Indonesia who were at risk of being infected with
HIV (Ministry of Health of the Republic of Indonesia,
2003). Some of the
groups identified as
being vulnerable to
HIV infection are IDUs;
female sex workers;
male clients of female
sex workers; men who
have sex with men
(MSM), including male
sex workers and gays;
transvestites and their
clients; and sexual
FIGURE 1. Estimates of groups vulnerable to HIV transmission up until 2002.
partners of people in
Note. IDUs = injection drug users. From the Ministry of Health of the Republic of Indonesia
these groups.
(2003).
335
The Current Situation of the HIV/AIDS
Epidemic in Indonesia
of shared needles that have
not been sterilized (Figure 3).
A study of IDUs in Jakarta,
Surabaya, and Bandung by
the Center for Health Research
of the University of Indonesia
shows that the majority of IDUs
live with their families and have
at least a high school education.
Although they are all aware that
the use of needles that have not
been sterilized can lead to HIV
FIGURE 2. The increase in HIV incidence among injection drug users in two drug rehabili- infection, a large percentage
tation centers.
of them nevertheless persist in
Note. From the Ministry of Health of the Republic of Indonesia (2003).
sharing.
Based on HIV sentinel surveillance results and a
The use of illicit drugs is not limited to lower
number of studies on these vulnerable groups, it is
socioeconomic groups but also involves the younger
estimated that about 90,000 to 130,000 people had
generation in urban areas who wish to experiment
been infected with HIV by the year 2002. About 25%
and are susceptible to the influence of their peers.
of these were women. Overall, injection drug use
As access to illicit drugs becomes progressively
and clients of sex workers constitute the majority of
easier, the number of users is on the increase and is
people infected with HIV. It is estimated that 14% of
spreading through all levels of society. The results of
the regular sexual partners (wives or husbands) of
a behavioral survey conducted in Jakarta show that
people belonging to these groups have been infected
about 30% of high school students have tried illicit
with HIV (Figure 1). Unfortunately, HIV prevention
drugs (Figure 4).
activities have rarely reached the regular partners of
individuals belonging to these at-risk groups.
It is not easy to implement behavioral change in the
IDU community because stigma and erroneous beliefs
HIV Transmission Among IDUs
are still widespread. Addiction can be considered as a
There was estimated to be between 124,000 and
chronic illness that can be cured. However, IDUs are
196,000 IDUs in Indonesia as of the end of 2002
considered to be criminals in Indonesia, rather than
(Ministry of Health of the Republic of Indonesia,
people suffering from an illness who need help.
2003). The spread of illicit drug use in urban areas in
Indonesia is quite alarming, especially since many of
these users are young. The sharing of needles
that have not been sterilized has resulted in
the relatively rapid spread not only of HIV but
also of the hepatitis C virus.
The high rate of HIV transmission among IDUs is
understandable, given the rather high numbers
of users of illicit drugs, including injection
drugs, and the fact that HIV spreads very easily
through the use of unsterilized needles. Testing
of IDUs being treated at drug rehabilitation
centers in Jakarta indicates an extremely rapid
increase in HIV prevalence, reaching 45-48%
in 2001 (Figure 2). The IDUs that have already
been infected with HIV become sources of new
infection for other IDUs, simply due to the use
336
FIGURE 3. The injecting risks among IDUs in Jakarta.
Note. Almost all IDUs in Jakarta report some injecting risk in the past week. From the Ministry of Health of the Republic of Indonesia & Center for Health Research, University of Indonesia (2003).
FIGURE 4. Behavioral survey among high school students in Jakarta, 2002.
Note. From the Ministry of Health of the Republic of Indonesia and the Central Bureau of
Statistics (2002).
Moreover, IDUs practice unsafe sexual behaviors,
such as buying sexual services but not using
condoms (Figure 5). Given that almost half of all
IDUs are infected with HIV, such unsafe practices will
result in the spread of HIV to noninjectors. It is only
by avoiding the sharing of unsterilized needles and
by using condoms during all sexual activity that the
spread of HIV can be prevented, not only to fellow
IDUs but also to noninjectors.
Undertaking a behavioral change intervention is
a real challenge. If interventions among IDUs are
successful, we will be able to prevent a significant
portion of the HIV infections that would otherwise
have been transmitted. Such efforts benefit the
health of the community in general, not only because
they help prevent new HIV infections among IDUs
themselves, but at the same time, they help prevent
the spread of HIV infections to other risk groups
and, most important, to their spouses and children.
A rapid increase in HIV infections among IDUs can
cause an increase in the transmission of HIV infection
through unsafe sexual behaviors.
Parallel with the increase in the number of people
addicted to illicit drugs, there is also an increase in
HIV infection among people in detention centers
and prisons/correctional institutions (Figure 6). HIV
infection is also continuing to increase in detention
centers and in other correctional institutions. Because
facilities are very limited, the sharing of needles that
have not been sterilized will continue to increase the
risk of infection. Until now, very limited prevention
and treatment activities have been implemented to
In view of the sharp increase in HIV transmission
during the past few years, it is time for HIV prevention
efforts to reach out to prisoners. The current situation
indicates the presence of sexual risk behavior that
allows for transmission, and it is quite possible that the
majority of prisoners have not obtained information
relating to means of infection and its prevention.
Risky Sexual Behavior In Indonesia
Commercial sex is growing very fast in all corners of
the archipelago and varies widely in scale. Women
who sell sex can be classified into two categories,
those who sell sex directly and those who do so
indirectly. Direct sex workers are those who sell sex
services in red-light areas, brothels, or on the street;
indirect sex workers generally work under the cover
of recreational and fitness enterprises, such as bars,
karaoke, massage parlors, and so on.
There are an estimated 190,000 to 270,000 female sex
workers in Indonesia and approximately 7 million to
10 million men who are clients of sex workers. More
than 50% of these male clients have regular partners
or are married. Unfortunately, fewer than 10% of
them consistently use condoms to avoid being
infected with STIs, including HIV.
Results of HIV surveillance show an increase in
HIV infection among FSWs (Figure 7). If we do not
succeed in increasing the level of condom use during
commercial sex, disease transmission will continue
to occur, not only from sex workers to clients and vice
versa but also to spouses (regular partners) of clients.
337
decrease the risk of HIV infection among
prisoners. The risk of infection will be even
greater if unsafe sexual behavior without
the use of condoms is practiced in prisons
and detention centers. The reported level
of sexually transmitted infections (STIs)
among convicts was about 10% in 2001.
This percentage is an indication of the
presence of sexual risk behavior among
prisoners. HIV transmission can spread
even further when prisoners return to
their families. Infection can be transmitted
to their sexual partners, especially from
those who are not aware that they have
been infected and have no knowledge of
HIV prevention methods.
O
S
83
The impact of unsafe
sexual
behavior
is
indicated
by
the
relatively high level of
HIV and history of STIs,
particularly
among
transvestites
(Figure
9). STI treatment must
be provided to lower
the risk of HIV infection
among groups in which
STI occurrence is high.
FIGURE 5. The sexual risk behavior among injection drug users (IDUs) in Jakarta. Waria =
transvestite (sex worker).
Note. In the past year, many IDUs in Jakarta had sex with more than one partner, and condom use is rare, an efficient way to spread the epidemic into other populations. From the
Ministry of Health of the Republic of Indonesia and Center for Health Research University
of Indonesia (2003).
Sexual services are not limited to female sex workers.
On a smaller scale, commercial sex is also being
provided by male sex workers and transvestites. The
increase in unsafe sexual behavior in Indonesia is
not limited to heterosexuals but also includes MSM,
among others, such as transvestite sex workers,
male sex workers, and gays. Male sexual behavior
appears to be much more complex, because there
are men who enjoy sexual relations with other men,
with women, and/or with transvestites. The fact that
there are men in Indonesia who are oriented toward
or choose to have sexual relations with others of the
same sex produces yet another kind of sex industry.
Sex services offered by transvestites, as well as those
offered by males to other males, have increased in
large towns in Indonesia.
Adolescent Risk
Behaviors
Behavioral surveillance
survey results from high
school students in Jakarta indicate that 8%of male
students and 5%of female students have had sexual
relations. About 30% of male students and 6%of
female students have tried illicit drugs (see Figure 4).
About 2% have used injection drugs. Knowing that
risk behavior begins in adolescence, educational
programs are needed that teach about the risks of
infection and appropriate methods of prevention, such
as avoiding sex and the use of addictive substances.
Adolescents like to experiment and are vulnerable to
friends’ influence, but they lack the knowledge and
skills for self-protection. Thus, we must try to ensure
that adolescents do not practice the kind of unsafe
behavior that can lead to HIV transmission. The world
has pledged to decrease the global incidence of HIV
The HIV epidemic among prisoners
There has been a very sharp increase in HIV
infection among transvestites compared
with previous years (Figure 8), from 6% in
1997 to 21.7% in 2002. This sharp increase
also occurred in other groups that frequently
practice anal sex without using any
protection. Today, it is estimated that there
are approximately 1.2 million (600,000-1.7
million) people categorized as gay, about
8,000 to 15,000 transvestites, and about 2,500
male sex workers. Results of a behavioral
study and serologic survey carried out among
MSM indicate unsafe sexual behavior, namely
anal sex without the use of condoms and
lubricants. Lubricants are used in anal sex to
avoid mucosal tears in the anus and rectum,
which increase the likelihood of HIV infection.
338
FIGURE 6. The increase in HIV occurrence among prisoners in Salemba Prison in Jakarta
and the increase in prisoners committing drug-related crimes in Indonesia.
Note. From the Ministry of Health, of the Republic of Indonesia, and the National Narcotics Board (2002).
It is well understood that
the real picture of the HIV
epidemic in Indonesia is
made up of several epidemics
FIGURE 7. The increase in HIV occurrence among FSWs in sentinel sites.
in
different
provinces,
Note. From the Ministry of Health, of the Republic of Indonesia (2002).
regions, and cities/towns.
There is also a variety of
by three quarters among young people between the
levels between different
ages of 15 and 24 by the year 2010. The effort needs
subgroups. It is clear that high HIV transmission
to begin right now to reduce vulnerability, as well
occurs among IDUs, sex workers, and street-based
as to increase young people’s skills in avoiding risky
transvestite sex workers.
sex and the use of illicit drugs. This effort should be
carried out in a structured way to ensure
that it reaches the younger generation
who are outside the school system, as
well as those who are still in school.
The Dynamics Of HIV
Transmission In Indonesia
HIV transmission has picked up speed,
and more people have become infected.
There is full awareness that the spread
of HIV continues to expand, due to
the interaction between groups that
are vulnerable to HIV, as well as their
interactions with society in general. In
fact, members of society in general are
also now at risk.
FIGURE 8. HIV occurrence among transvestite sex workers in Jakarta, 1993-2002.
Note. From the Center for Health Research, University of Indonesia, & Ministry of Health
of the Republic of Indonesia (2002).
HIV seroprevalence levels among blood
donations nationally and in Jakarta were very low
in the early 1990s but have been rising consistently,
particularly since 1998 (Figure 10). If the results in
blood donors are considered to be representative of
the low-risk population, the findings among blood
donations suggest that HIV infection is moving to the
“low-risk population” in Indonesia.
The HIV epidemic patterns in different Asian
countries have certain similarities, although there
are differences in scale and in time. At the initial
stage, HIV infections occur within certain at-risk
subpopulations and then spread from this group to
The results of behavioral surveys carried out among
various groups that are vulnerable to HIV infection
in different towns in Indonesia indicate that these
groups practice unsafe sexual behaviors with other
risk groups (Figure 11). Significantly, there is also a
particularly high frequency of unsafe sexual activity
and shared needle use among IDUs. A very high
proportion of male sex workers are also having sex
with women, further spreading STIs and HIV.
A model of the transmission channels between the
groups is shown in Figure 12. This interchange is a
crucial factor in the spread of the HIV epidemic; the
339
other larger populations.
The epidemic occurs within
groups of IDUs, MSM, sex
workers and their clients,
and regular partners (wives
or husbands) of members of
these risk groups.
influence of very conservative
Moslem leaders who feel
that such activities promote
extramarital sex and drug use.
Further, drug use is a criminal
offense in Indonesia. Vigorous
enforcement of this law drives
drug users “underground”
and promotes sharing of
drug paraphernalia, seriously
hindering implementation of
harm reduction strategies.
Treatment
In December 2003 the
government
launched
a
treatment program utilizing
generic antiretrovial drugs
at a reduced price. They hope to have 1,500 HIVinfected person on treatment by 2005. Effective
treatment, however, will depend on identifying HIVinfected persons early in the course of their disease
(made difficult by the high level of stigmatization)
and developing an infrastructure capable of clinical
management of the patients.
FIGURE 9. HIV and STI occurrence among men who have sex with men in Jakarta, 2002.
Note. From the Center for Health Research, University of Indonesia, & Ministry of Health
of the Republic of Indonesia (2002).
high HIV prevalence among IDUs can thus spread
HIV to sex workers, and from them to sex workers’
clients, and on to their sexual partners (both wives
and husbands). It is very clear that HIV transmission
channels are no longer limited to high-risk behavioral
groups; they infiltrate other groups, including groups
with low-risk behaviors.
The HIV epidemic in Indonesia has already taken off.
Will HIV infection continue to proliferate? With the
level of HIV infections on the increase, and given the
phenomenon of expanding channels of transmission,
the potential for the HIV epidemic to spread further
in Indonesia will become even greater if more serious
efforts for HIV prevention are not made.
Intervention Constraints
The government of Indonesia has responded to the
recent increase in HIV-infected persons by developing
a national strategic plan and strengthening the
National AIDS Committee. Funds to support
intervention activities, however, are still limited. The
majority of funding comes from donor agencies
and nongovernmental organizations (NGOs) whose
agendas are not necessarily commensurate with the
government’s. A recent survey among IDUs and MSM
in three provinces indicated that very few of them
had been exposed to intervention activities.
A major barrier to promotion of harm reduction
strategies, such as needle/syringe exchange
programs and condom promotion, is the strong
340
Necessary Responses to The HIV
Epidemic In Indonesia
Behavioral change efforts are needed that can
access the at-risk groups. It is clear, however, that
we do not yet have the capacity to reach a large
portion of vulnerable groups. In addition, those who
have already been reached through the program
have evidently not been motivated to change their
behavior. It is hoped that future prevention efforts will
be given serious support from all components within
the country so that the negative impacts of HIV can
be prevented. Based on the available evidence, there
is a need for a prevention effort that is more focused
FIGURE 10. Prevalence of HIV infection among blood donors 1992-2002.
Note. From the Ministry of Health of the Republic of Indonesia and the National Transfusion Unit (2002).
Male sex workers
with gays (unpaid)
Gays with women
Male sex workers
with FSW
Male sex workers
with transvestites
Transvestites with
male sex workers
Male sex worker
FIGURE 11. Mixed sexual transmission between risk groups.
Note. From the Central Bureau of Statistics & Ministry of Health of the Republic of Indonesia (2002).
and that has extensive reach, one that has significant
impact in preventing new HIV infections in both the
short and long term.
The dynamics of the HIV epidemic in Indonesia are
heavily influenced by the interactions between
various at-risk groups. Outreach to high-risk groups
such as IDUs is needed, in the hope that provision
of clean needles and condoms on a larger scale
will prevent HIV and the hepatitis C virus from
spreading.
Taking into consideration the fact that there is also
a risk of HIV transmission in detention centers and
prisons/correctional institutions, efforts are needed
to increase the understanding of the ways in which
HIV spreads, as well as ways of preventing it among
prisoners.
Young people need to receive comprehensive
information on the means of HIV transmission and its
prevention, as well as skills in avoiding risk behavior.
Such knowledge and skills need to be disseminated
as early as possible, both in schools and outside. It is
hoped that in this way, a significant proportion of the
young generation in Indonesia will be able to reject
unsafe behavior.
Given the fact that male clients of sex workers can
play a very important role in reducing transmission
by always using condoms
during
risky
sexual
activity, high priority
should be given to
providing
information
that motivates a change
of behavior among these
men. In Indonesia, where
there is inter-high-risk
group transmission, as
well as transmission to
low-risk groups through
sexual relations, the use
of condoms would not
only prevent transmission
between at-risk groups
but also prevent further
transmissions to low-risk
groups, namely, their
regular partners or wives,
as well as their children.
Current efforts are still inadequate and have not
yet reached many of the vulnerable groups. The
maximum impact is expected through prevention
efforts that are more focused on groups with high
rates of transmission, such as sex workers, MSM, and
IDUs. To date, efforts have been limited to certain
groups and have also had limited coverage.
A strategic plan for prevention has been drawn
up and will be used as a basis for the national
strategic plan for HIV/AIDS prevention. The activities
that have been set out in this strategy include
promotion of a healthy lifestyle, safe sexual behavior,
condom promotion, STI treatment, the use of safe
needles, and support for people with HIV/AIDS.
HIV prevention activities have been carried out
through the cooperation of various parties, such
as donor organizations, community self-help
organizations and NGOs, and other groups concerned
about the HIV/AIDS epidemic in Indonesia.
Conclusions
Obvious efforts that can be put into action
immediately are needed. We need to increase and
widen HIV prevention efforts, we need support from
all sectors, and we need concerted action that is
not limited either to the government sector or the
341
IDUs with FSW
FIGURE 12. Potential mechanism of sexual transmission of HIV in Indonesia, from one risk
group to another, through contacts without condoms.
References
community. This is the only way that the spread of
the HIV epidemic in Indonesia can be prevented.
Center forHealthResearch, University of Indonesia, & Ministry
of Health of the Republic of Indonesia. (2002a). A study of
injecting drug user behavior in three cities: Surabaya, Jakarta
and Bandung.
It is hoped that prevention efforts will be able to
avert new cases of HIV. However, if prevention efforts
are not stepped up intensively, and in a way that can
reach groups that are vulnerable to HIV, it will be
difficult to avoid new infections.
Center forHealthResearch, University of Indonesia, & Ministry
of Health. (2002b). A study of men who have sex with men
behavior in three cities: Surabaya, Jakarta and Batam, 2002.
Central Bureau of Statistics&Ministry of Health of the Republic of
Indonesia. (2003). The report of Behavioral Surveillance Survey
in Indonesia, 2003.
Ministry of Health of the Republic of Indonesia. (2003). Workshop
report on national estimates of adult HIV infection in Indonesia
at September 2002.
342
Public Health The Leading Force of
The Indonesian Response to The HIV/AIDS
Crisis Among People Who Inject Drugs
Fabio Mesquita1
Inang Winarso2
Ingrid I Atmosukarto1
Bambang Eka1
Laura Nevendorff1
Amala Rahmah1
Patri Handoyo3
Priscillia Anastasia3
Rosi Angela4
1
Indonesia HIV/AIDS Prevention and Care Project, Jakarta, Indonesia.
2
Indonesia National AIDS Commission, Jakarta, Indonesia.
3
Indonesia HIV/AIDS Prevention and Care Project, Bandung, Indonesia.
4
Indonesia HIV/AIDS Prevention and Care Project, Bali, Indonesia.
Harm Reduct J. 2007 Feb 17;4:9
BioMed Central
343
Abstract
Issue: Indonesia has an explosive HIV/AIDS epidemic starting from the beginning of this century, and it is in process to build its response.
Reported AIDS cases doubled from 2003 – 2004, and approximately 54% of these cases are in people who inject drugs.
Setting: Indonesia is the 4th largest country in population in the world, a predominantly Muslim country with strong views on drug users and
people living with HIV/AIDS. Globally speaking, Indonesia has one of the most explosive epidemics in recent years.
The project: IHPCP (Indonesia HIV/AIDS Prevention and Care Project) is a joint support project (primarily AusAID-based) that works in partnership
with the Government of Indonesia. IHPCP has been a key player of in the country’s response, particularly pioneering NSP; stimulating and
supporting methadone programs, and being key in promoting ARV for people who currently inject drugs. The project works via both the public
health system and NGOs.
Outcomes: It is still early to measure the impact of current interventions; however, this paper describes the current status of Indonesia’s response
to the HIV/AIDS crisis among people who inject drugs, and analyses future challenges of the epidemic in Indonesia.
Introduction
According to the last UNAIDS report on the global
HIV/AIDS epidemic, the core expansion of the HIV/
AIDS epidemic (absolute number of cases reported)
is currently based on injecting drug use in Asia
and Eastern Europe [1]. India recently achieved the
biggest number of reported AIDS cases of any country
globally, however the two major epidemics in Asia –
mainly driven by injecting drug use – are in China and
Indonesia. This paper reports the current situation in
Indonesia by the end of 2006, and how the national
response to this crisis is being built by the Indonesian
government, civil society and external partners.
Indonesia is a country of approximately 17,000 islands,
with the fourth largest population in the world. It is a
predominantly Muslim country with strong views on
drug users, sex (use of condoms) and people living
with HIV/ AIDS.
After 32 years dominated by a military dictatorship,
the democratization process is very recent,
having started in 1998. As part of this process,
decentralization of power and budgets, and
consequently decentralization of the responsibilities
on public policies and governance, has a clear impact
on the public health system. As time passes, cities,
districts and provinces are addressing the alignment
of responsibilities in public health matters. The
decentralization of the response to the HIV/AIDS
epidemic is an ongoing process with increasing
responsibilities shared among different levels of
government.
The epidemic of HIV/AIDS in Indonesia reported its
first case of AIDS in 1987. The first reported AIDS case
among people who inject drugs (IDU) was in 1995.
Since then, IDUs have constituted a major component
of the country’s epidemic [2]. According to the Centre
for Disease Control (CDC) of the Ministry of Health of
Indonesia, reported AIDS cases doubled from 2003 –
2004, and approximately 80% of the new cases in the
last two years are among people who inject drugs.
Cumulatively, transmission of HIV related to the use
of injectable drugs accounts for 54% of the total AIDS
cases in the country [3]. National estimates indicate
that the number of people living with HIV/AIDS
ranges from 165,000 to 216,000 [4]. Widespread,
free access to an HIV test is a recent phenomenon;
the logistics of the system is still being worked out.
Available data is not accurate; there is as well the
need to increase quality of data collection and flux of
the information.
Currently, there are many bodies of the Government
playing a role in the control of the HIV/AIDS epidemic,
primarily the KPA or the National Commission on
AIDS, which has been attached to the Presidential
345
Public Health The Leading Force of
The Indonesian Response to The HIV/AIDS Crisis
Among People Who Inject Drugs
Cabinet from July 2006. With a recently empowered
strong leadership, KPA is in the process of recruitment
to build their internal team with some of the best
staff in the field of HIV/AIDS in the country and
has a very promising role in response leadership.
KPA is not involved in policy implementation, but
rather responsible for formulating policies, and
works mainly with international sources – centred
on DFID, the British Cooperation – via partnership
funds, which are administrated by UNDP. UNAIDS is
the multilateral organization that provides technical
support to KPA.
The Ministry of Health is responsible for
implementating the response to the HIV/AIDS
epidemic, comprised of four departments. The
Pharmacy Department is responsible for all
medications. The Centre for Diseases Control includes
the National AIDS Program which is responsible
for program development, building local human
resources and for all matters related to epidemiology.
The Department of Medical Services runs all the
hospitals, the Drug Program (including methadone
clinics), and all laboratories. Lastly, the Community
Health Department is responsible for the Community
Public Health Centres (Puskesmas) programs. It has
been somewhat difficult to integrate all departments
in one coordinated implementation of the HIV/HIV/
AIDS response. WHO is the multilateral organization
that works closely with the Ministry of Health to assist
the Indonesian national response.
At the national level in the harm reduction field is the
National Narcotic Board (BNN), which is attached to
the National Police. This body is also responsible for
narcotic demand and supply reduction, their primary
focus. Also related to this effort is the Ministry of
Justice and Human Rights, which runs prisons in the
country and is responsible for every intervention
inside the prison system.
In addition to the Indonesian government sectors,
the international community is involved in the
country’s HIV/AIDS response. Indonesia received $64
million US from the fourth round of the Global Fund
with a project whose scope contains what is required
to confront the epidemic, including a detailed cost
study build in the WHO model (Costing Guidelines
for HIV/AIDS Intervention Strategies). The Ministry
of Health, through the Centre for Disease Control,
leads the implementation of the Global Fund project.
346
Unfortunately in Indonesia, administration of the
Global Fund sources has led to a “D” classification,
with results below expectations [5]. National and
international experts in the country agree that the
lack of good reporting process could be influential
in establishing this classification. In addition to
the Global Fund, DFID, USAID, AusAID and KFW
are working in Indonesia in the field of HIV/AIDS.
WHO, UNAIDS and recently UNODC, among other
UN agencies, also have a strong influence on the
response thus far. Other international agencies have
minor influence in specific aspects of the response in
Indonesia.
In addition to the efforts from the Indonesian national
government and international partners, there are local
responses organized in several provinces and cities,
in conjunction with the decentralization process
already mentioned. Commitments are different
based on the specific local history and importance of
the epidemic, as well as the political climate of the
various local governments. To complete this complex
framework, Non-Governmental Organizations (NGOs)
were involved at the onset and are still crucial in the
Indonesian response to the HIV/ AIDS epidemic.
With permeable borders in its 17,000 islands,
geographically close to the Golden Triangle, and
as well not greatly distant from Afghanistan, since
the late 90s, Indonesia has become a great market
for heroin, and currently also a rising market for
amphetamines. In its 2005 report, the National
Narcotics Board indicated that there are 3.2 million
drug users in Indonesia of which 25% are heavily
addicted and injecting drugs [6]. Still, according to
BNN, the trends of drug use are measured by drug
treatment admissions in hospitals, admissions in
rehabilitation centres, drug seizures, prisons for drug
offences, and injecting drug users reported by the
Ministry of Health as AIDS cases. According to the
sum total of this information, marijuana is the number
one drug of abuse, followed by heroin, amphetamine
type stimulants (ATS), hashish and cocaine. There
is an increased availability of night drugs such as
ecstasy also available in Indonesia. Poly-drug use,
sedative hypnotic drugs and drugs of inhalation
are also being reported. As already mentioned, BNN
manages demand reduction, which for Indonesia
includes: “prevention (family based, school based,
community based and workplace based) treatment
and rehabilitation activities in both public, NGO, and
private facilities, employing various modalities. Supply
At the early stage of the epidemic among drug users
in the late 90’s, the response was dominated by NGOs
supported by international aid agencies such as
USAID and AUSAID [9]. Local governments were not
showing the commitment needed for the response
while the central government was just beginning
to get more exposure to the problem and to harm
reduction approaches.
Regarding harm reduction, the first recorded NGO
organizing harm reduction services was Yayasan
Hati-hati (Balibased) in 1998. Since then, more
organizations developed in many parts of the country,
the majority founded after the beginning of the 21st
century. All of these organizations are made up of
people with previous experience in the drug field
(the majority former drug users) to address the AIDS
epidemic among IDUs. Yet their connection within the
AIDS social movement has been weak. Meanwhile,
these organizations had modestly better connections
with the international platform, especially more
recently. Their primary source of financial support is
international donors (mainly bilateral projects – in
particular, IHPCP/AusAID and FHI/USAID), with the
exception of a few organizations with diversified
donors and partners. Interestingly, their activities
have not put much emphasize on activism, and have
not exhibited much responsibility in fighting for the
rights of drug users (e.g., guaranteed access to ARV,
better laws, better policies and other basic issues of
global human rights NGOs). Such advocacy is being
promoted by IHPCP and more recently by the Open
Society Institute as well.
Thus, despite the growing commitment by all players
especially in recent years, all are convinced that the
response to the HIV/AIDS epidemic so far is insufficient
for the size of the problem. The dominance of NGOs
has proved ineffective in scaling up efforts of AIDS
services, particularly for IDUs.
In response to the problem, IHPCP’s latest
commitment in harm reduction has been to include
the public health system in the service of AIDS to
drug users and the empowerment of drug users as
Indonesian citizens for universal access to health
care.
Description of The Response So Far And
The Role of IHPCP
The Indonesian response to the HIV/AIDS crisis
among people who inject drugs is still modest.
There is a clear consensus among stakeholders
of an urgent need to scale up the response to the
epidemic. In total, 41 NGOs are working in the field
of harm reduction. Among these, 16 are conducting
needle and syringe program projects, targeting 4,500
people who inject drugs on a monthly basis, all but
one of these 16 NGOs supported by IHPCP. The other
25 organizations started modest syringe distribution
after the second semester of 2006 with funding from
the Partnership and the Global Fund, and they are
partners of Family Health International in Indonesia.
Besides NGOs, public health centres (Puskesmas)
are also conducting harm reduction activities,
including needle and syringe exchange. In July 2005
only one Puskesmas from Jakarta was developing
harm reduction activities in Indonesia. By 2006,
this had increased to 65. IHPCP and the local AIDS
commissions are sharing the cost of these facilities
for one year, with the commitment that future costs
will be fully borne by the government. In September
2006, the City of Bandung Public Health Department
in West Java, with their own funds, opened another
9 NSP in Public Health Centres. IHPCP provided
technical support for planning and staff capacity
building. So the current total of NSP slots in Indonesia
by December of 2006 is actually 115.
These public health centres are targeting to reach
another 23,000 people who inject drugs. The
interaction of public health services and nongovernmental organizations is the key element of
interventions to scale up the response in the country.
The role of the Public Health Centres, especially in the
347
Reduction Strategies are implemented through more
intensive eradication of cannabis cultivation, intensive
investigations and raids of clandestine manufacturers
and applying strict airport and seaport interdictions”
[7]. Burnet Institute’s Centre for Harm Reduction in
collaboration with the Turning Point Alcohol and
Drug Centre conducted a recent situational analysis
in Indonesia (as well as other countries in Asia) on
behalf of the Australian National Council on Drugs
and found similar information on drugs, drug supply
and demand reduction [8]. Under the Indonesian
legislation, the use of drug is criminal (this is also
true of possession) and trafficking is punishable
by the death penalty. The strict criminalization of
drug use behaviours has made it difficult to reach
injecting drug users for health care services and harm
reduction programs.
capital region of Jakarta and West Java (two of the
main provinces of Indonesia) is to lead the response
and use the infrastructure of the health system to
scale the response to the level of the epidemic. The
expansion was based on a successful experience
conducted in the City of Sao Paulo, Brazil, from 2001 to
the present [10]. Today the aim of the current projects
is to achieve treatment of 30% of the injecting drug
users in the country but because most efforts are new
projects, the coverage is approximately 10% of the
target. The scale-up proposed by KPA aims to achieve
70% of IDUs by 2010. At the beginning of 2005 (after
almost 7 years of the first NEP in Indonesia), most of the
NEPs were still focused on the distribution/exchange
of syringes only. Our effort after 2005 was to change
the intervention for a comprehensive prevention
package which includes, besides the sterile syringes,
condoms, alcohol swabs, IEC (information, education,
communication) material; projects conducted mainly
on an outreach basis with a strong connection to the
health system for referral in basic health care, drug
treatment (highlighting methadone), and support
and treatment for drug users at risk for HIV/AIDS.
The work in prison is another front of harm reduction
work in Indonesia. In June 2005, the Ministry of Justice
and Human Rights launched the National Strategy for
Prevention and Control of HIV/AIDS and Drug Abuse
in Indonesian Correction and Detention Centres, for
the period 2005–2009 [11]. The document detailing
this program, the first of its kind in Asia, provides the
framework for the work of prevention, care, support,
and treatment of the HIV/AIDS epidemic inside the
prison system. It was constructed with intensive
input from IHPCP and other donors as well. Currently,
only a few of the 396 prisons in Indonesia provide
CST and HIV prevention; however some potentially
effective demonstration projects are ongoing. The
gold standard is the Balinese prison of Kerobokan
where distribution of bleach and condoms for
prisoners, as well as treatment with methadone and
ARV are made available [12]. The central issue on the
prison response to HIV/AIDS epidemic is the urgent
need of increasing these interventions to address
the sizeable problem. KPA’s strategic plan is to cover
95 prisons by 2010, 20 of them with comprehensive
programs like the one in Bali.
Drug treatment in Indonesia is primarily based on
drug free clinics for detoxification and rehabilitation,
normally conducted by mental hospitals, NGOs
or therapeutic communities. There is no official
compulsory treatment in Indonesia. Buprenorphine
is still expensive and not widely available. So far,
approximately 300 doctors (mostly private doctors)
across the country are certified to prescribe
Buprenorphine. As well, anecdotal reports from IDUs
in several provinces including Bali, West Java and other
egions indicate a high rate of injecting Buprenorphine
as heroin becomes scarcer in the market. Methadone
was established first in Indonesia in 2003 by WHO
and the Ministry of Health in two pilot projects, one
in Jakarta and one in Bali. These two pilots together
existed until the end of 2005, serving a population
of approximately 300 drug users. Since 2004, IHPC
has supported the main expenses of these two
projects. Under the political influence of BNN in June
2005 (during the Anti-Drug World Day), Indonesian
President Suscilo Bambang Yudoyono visited one
of the clinics and announced a public program to
expand methadone use based on its success so far. The
expansion of methadone really started in 2006. By the
end of 2006 there were 7 clinics serving approximately
1,000 clients. KPA’s plan is to increase the number of
drug users treated to more than 50,000 by 2010.
The legal basis for the Indonesian Response to HIV/
AIDS among people who inject drugs is for the most
part based on policy. Legislation in Indonesia is under
debate to allow programs to assist in controlling the
epidemic. There is no law against harm reduction
in Indonesia, but prejudicial interpretation and
misinterpretation of the current laws (all in effect
before the HIV/AIDS epidemic) have resulted in many
constraints, primarily in the realm of prevention. The
Sentani Commitment signed in January of 2004 by
the Head of the National AIDS Commission and many
other authorities in Indonesia – and reedited clearly
delineating needle and syringe programs, as well as
methadone programs – in June of 2005 is the main
document supporting harm reduction activities in
the country [13]. Memorandums of Understanding
signed between ministers are also important
support documents, such as those signed by the
National AIDS Commission and the National Bureau
on Narcotics. Public statements from authorities,
including the President and the Vice-President
of Indonesia, clearly supported harm reduction
programs as well. Local authorities, such as the ViceGovernors of DKI Jakarta, West Java and Bali, but not
limited to these officials, are publicly also supportive
of harm reduction, including the commitment of their
provinces’ budgets to support the scaling up of the
348
treatment, about 25% are in treatment. This data takes
into account equal likelihood for current or former
injecting drug users. If we also consider the personal
decisions of doctors who misunderstand the need for
involving current injecting drug users in needed ARV
treatment, this will likely worsen this scenario.
Advocacy of the police is the most difficult part of
the job. Indonesia has a history of militarization
of the street police that is still currently in effect.
Police officers are underpaid, under-trained and
under-equipped in Indonesia. As in many other
countries, the police are susceptible to corruption
and the use of unnecessary force. Politicized and
influential, positions often change and sometimes all
expenditures related to a specific advocate decrease
or even disappear as a result of constant changes
and are subsequently re-introduced. This can make
for noticeable cost inefficiency.
By 2006 IHPCP had attempted to stimulate among
doctors in Indonesia the potential benefit of WHO and
several other organizations to increase the number
of current injecting drug users for ARV treatment
[16]. From the previously mentioned 65 Public
Health Centres are already actively engaged in NSP,
11 received training for implementation of VCT and
ARV availability in community health centre settings.
The joint initiative from IHPCP with the Indonesian
Association of Doctors working with AIDS (PDPAI –
Perhimpunan Dokter Peduli AIDS Indonesia) is also
helping to promote the education of doctors in the
country for universal access.
The concept of universal access to AIDS treatment
is new to Indonesia. The policy of free and universal
access for ARV was implemented in 2004. According
to the 3 × 5 initiative of WHO, Indonesia was recorded
as having 10,000 people with AIDS (in need of ARV)
by the end of 2005, of which 4,000, or 40% of the
target, had been treated with ARV.
In Indonesia, national production of ARV is done
by Kimia Farma, an Indonesian Governmental
Pharmaceutical Company contracted by the Ministry
of Health. First line medications produced in the
country are Zidovudine, Nevirapine and Lamivudine.
Indonesia has also made available other ARVs by
import: Efavirenz; Stavudine and lopinavir + ritonavir
- Kaletra [14] and gradually is increasing the choices.
ARV is free of charge in the universal access spirit since
the end of 2004; however ARV free of charge does
not mean easy and free access. A CD4 account is still
paid by the client with a cost of around US$ 13.00,
an expensive blood test for Indonesians. Doctors still
charge for the cost of consultation. It should be noted
that about 20% of Indonesians are subsidized by the
government based on poverty; thus, they obtain free
health care, but 80% of the population still pays for
health care.
A recent global review estimates that in Indonesia,
people who inject drugs are about 31% of the people
treated with ARV [15]. Thus, of the entire population
of individuals who use injected drugs needing ARV
Formally, Indonesia is the only country in Asia that
does not restrict people who inject drugs (including
current users) from access to ARV treatment, and it
is one of the few countries that produce the first line
of ARVs for its own consumption. The KPA strategic
plan has the provision to extend care, support and
treatment of people who inject drugs to a total of 75
Public Health Centres (Puskesmas) by 2010, doubling
the current possibilities for access.
Drug user participation is also currently a key
element of the growing Indonesian response to the
epidemic. Besides many NGOs made up of current
and former drug users, two networks highlight the
key participation of drug users. Jangkar is network of
organizations working in the field of AIDS, and IDUSA
is a Drug Users Individual Network. Both are obtaining
strong support for their activities from IHPCP and
other partners and are gradually being included in
all important governmental meetings and decisions.
Their agenda includes both the controlling of the
HIV/AIDS epidemic and the key issue of the human
rights of drug users.
The current scenario seems challenging. But realizing
that as recently as two to three years earlier the
current infrastructure for HIV/AIDS treatment was
not in place, it’s fair to say that currently, all the
components for a comprehensive response are in
place in Indonesia. The remaining question is how to
349
response. Some political resistance has arisen from
some sectors of the police that prefer to maintain a
focus on law enforcement, even though this strategy
has previously been shown to fail. Some religious
leaders are more resistant to the promotion of safe
sex than to the promotion of safer use of drugs.
expand this scenario, simultaneously guaranteeing
the quality of interventions.
Discussion and Conclusion
Indonesia, the third biggest country in Asia, is facing an
explosive epidemic driven by people who inject drugs.
Even in a very inhospitable political and social environment,
Indonesia is building a comprehensive response
spearheaded by the commitment of the Indonesian
government, province governments, civil society and
international agencies. The response among people who
inject drugs is being included in the public health system as
a key strategy to push for the needed expansion of services.
The role of the local governments is crucial, including their
political and budget commitments, as a strong step in
the sustainability of the response. The clear direction of
the key interventions to address the HIV/AIDS epidemic
that has affected Indonesia for the last 25 years is another
important result. The clear focus on NSP, methadone, and
care, support and treatment of people who inject drugs
speaks to what needs to be done to address the epidemic.
Initiatives from Indonesia such as the program to supply
methadone inside prisons, and the promotion of ARV for
current injecting drug users, are being perceived as the
gold standard for all of Asia, a continent severely impacted
by the HIV/AIDS epidemic. There is a long way to go in
Indonesia to significantly impact the epidemic and thus
celebrate the saving of thousands of lives, but the bases
are very well established.
As UNAIDS head Peter Piot stated: “...we need to do more of
the wonderful things we have been doing so far”.
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euro.who.int/aids/treatment/20060801_1].
Translated from Pengembangan Modul HIV& AIDS bagi Mahasiswa Kedokteran dengan Metode Belajar-berbasis Masalah.
Abraham Simatupang1
1
Department of Child Health, Medical School, Christian University of Indonesia.
Jurnal Pendidikan Kedokteran dan Profesi Kesehatan Indonesia. 2007; Sep 2(3):107-12
351
Development of HIV/AIDS Module for Medical
Students with Problem-based Learning Approach
Introduction
In 2006-2007 year of academic, the Faculty of MedicineUniversitas Kristen Indonesia (FM-UKI) started to
implement a new curriculum called competence-based
curriculum (CBC) consisting of 26 modules. Each module
has its own learning objectives learned from some
scenarios. Each scenario is written based on problembased learning (PBL). The scenario can be studied through
tutorial, group discussion private study, and group work.
Besides that, addition material is also delivered through
expert lecture as well as expert consultation. In tutorial
session, scenario is discussed using “seven jumps”1
approach. Briefly, seven jumps consists of:
Step 1 : Clarify terms and concepts not readily
comprehensible
Step 2 : Define the problem
Step 3 : “Brainstorming” session to discuss the
hypothesis or suggest possible explanation
Step 4 : Define hypothesis
Step 5 : Formulate learning objectives
Step 6 : Collect further information through private study
Step 7 : Group shares information and discuss results
of private study
PBL, every members, including tutor, have a role in
learning process (see Figure 1). Important element in
self directed learning can be seen in Box 1.1,2
Box 2. Example of Triggers in PBL scenario1
Clinical situation
Experiment or laboratorium data
Photos
Video clips
Newspaper articles, magazines
Articles (a part or whole part) of journal
Simulation patient
Family tree showing abnormality herited
Scenario
Scenario is written based on topic in topic tree. In
PBL context, scenario is used as a Dalam konteks
PBL, skenario is used as a hook or trigger to produce
actively learning process in tutorial class. There
are many examples that can be used as triggers in
scenario. In scenario, there are problem, data and
several medical words or terms which hopefully can
trigger discussion. Scenario is studied and discussed
with “seven jumps” method.
Box 1. Key principles of self-directed learning
Students have to be initiative to :
recognise needs of (topic/theme) which will be
learned
determine learning objectives
identify learning sources
do activities suitable for above specific needs
evaluate learning results
PBL method encourages the students both individually
and in group to explore problems, concept and
other things from scenario topic given during
tutorial themselves. This aproach needs students’
independence. Students are encouraged to do active
learning and self-directed learning. In addition, the
competence that have to be fullfiled according to
Indonesian education objectives generally and FMUKI specifically, also have to be completed with good
learning facilities, like comfortable discussion rooms,
proper on-line libraries, and sufficient skill-labs. In
Method
Module trial was openly and voluntarily done in
students from 7th to 8th semester who are not doing
other academic activites. The students took the trial
are students who are still in learning program with
former curriculum. They didn’t know and use to
PBL model. The students who were still doing other
academic activities, like organization committee
and short semester, were suggested not to take this
trial, because full participation of the students is
needed. Seventy five students took the trial divided
into 3 groups, each of which consists of: Group I, 19
(nineteen) people; Group II, 29 (twenty nine) people;
Group III, 27 (twenty seven) people (see Box 3).
Before the trial, the students were given some general
explanation telling about method and learning system
they would take. It was Problem-based learning (PBL)
using tutorial system, short lectures, and training
353
Development of HIV/AIDS Module for Medical
Students with Problem-based Learning Approach
throung skill-labs. Then, they took pre-test in multiple
choice question about HIV/AIDS. Group I and II got
module learning while Group III was control. After that,
all groups took post-test but only Group I and II took
OSCE and other multiple choice tests.
Box 3. Trial design
Recruitment
Group I : 19
Group II: 29
Group III (control): 27
asked or examined and during interaction process
with the students.
Evaluation of Learning Process
In this trial, the number of OSCE stations are 5 (five)
and in each station the students would be tested for
their competence in:
Station 1: Anamnesis
Station 2: Opportunistic infection
Station 4: Antiretroviral counselling
Station 5: Antiretroviral prescription
In station 1 there was simulation patient who was a
teacher staff acting as a patient with some characteristics
according to Special Intructional Objectives (Tujuan
Instruksional Khusus (TIK). Patient wanted to get health
examnination relating to symptomps caused by risky
sexual activity. In other stations, the students were
given modified-essay question.
Pre-test : all groups
Group I & II
Tutorial,
Short lecture, lab-skill
Data Collecting and Analysis
Post-test: all groups
Group I and II:
UPG & OSCE
Evaluation
Suggestion or feedback could be given by students
about simulation patient, OSCE process, feeling
or anything felt during OSCE test.1,8 Besides that,
simulation patient was also able to give feedback to
the students about anything they felt when they were
Tutor and students’scoring questionnaires, assessment
of modules were made in Likert scale. However, the
students also had a freedom to give their comment
writtenly. OSCE assessment paper was made with
include competence list and assessment, each of
what had 15 score. The score then was inputted to
excel table and moved to SPSS Ver.14 for counting
mean, and analysed with T-test. Data analysis result is
reviewed in Table and Figure below.
Results
The proportion of mean some appraisement
parameters in Table 1 and 2.
Table 1 The proportion of parameter value between male and female students
Gender
Male
Female
Total
X
N
SD
X
N
SD
X
N
SD
Pre
test
63.7
14
5.5
57.8
61
18.5
58.9
75
16.9
Post
test
71.3
4.8
69.1
61
15.1
69.5
13.8
55.6
General
Performance
51.8
14.1
25.0
38
10.8
23.8
37.0
68.4
38
31.7
65.9
9.4
54.2
38
9.2
53.8
11.6
32.7
9.2
MCQ
Raise
Anamnesis
VCT
IO
56.8
9
4.5
57.9
39
5.5
57.7
48
5.2
4.4
5
2.0
6.2
22
5.4
5.9
27
4.9
80.3
9
9.5
80.5
38
12.0
80.4
47
11.5
36.2
44.4
ARV
Couns.
18.9
17.1
40.0
38
17.7
39.3
37.1
44.2
38
30.2
44.2
17.4
31.1
Prescription
X: mean; MCQ: multiple choice question, VCT: voluntary counseling and testing; ARV Couns: Anti-RetroViral
Counselling
354
Group
1
2
3
Total
X
N
SD
X
N
SD
X
N
SD
X
N
SD
Pre
test
62.6
19
6.7
53.4
29
25.2
62.3
27
7.1
58.9
75
16.9
48.7
General
Performance
55.7
17.1
20.9
31.7
77.7
10.5
52.6
24.0
3.3
28.3
8.1
39.3
44.3
23.8
65.9
53.8
17.4
31.2
11.6
32.7
9.2
Anamnesis
VCT
IO
57.9
75.9
40.9
64.2
ARV
Couns.
28.2
5.8
68.3
5.8
57.6
17.8
38.2
30.2
30.7
19.8
65.8
27
6.5
69.5
75
13.8
4.9
9.4
83.5
28
11.9
17.4
80.4
47
11.5
Post
test
76.7
MCQ
57.7
48
5.3
Change
5.9
27
4.9
5.9
27
4.9
Prescription
X : mean; MCQ: multiple choice question, VCT: voluntary counseling and testing; ARV Couns: Anti-RetroViral
Counselling
Figure 1 Comparison between group 1, 2 (experiment), and 3 (control)
Discussion
The implementation of medical education with
Competency Based Curriculum (CBC) is an obligation,
not only because of instruction of Direktorat Jenderal
Pendidikan Tinggi (DikTi) Ministry of Education,
but also because of the encouragement from the
of internal medical and health world itself that
need the doctors with many competencies. These
competencies have been agreed in many world
educational medical associations. Competencies
which are needed for the doctors are effective
communication, basic clinical skill, medical
knowledge, life-long learning, self-awareness
and self-care, moral and ethic appraisal, problem
solving, and many more. Since the implementation
of CBC, FM-UKI immediately took some strategic
steps to reorganize the formerly lectured centered
curriculum and teacher-centered to active learning
and student-centered. This philosophy can be
implemented with Problem Based Learning (PBL).
The students are given the problems in scenario.
And then the students will analyzing with their own
prior knowledge to get new comprehensions. This
learning model is expected to be able to give lifelong learning lifestyle which is very fundamental
for every medical professional because of the rapid
development in knowledge and technology in
medical world. Furthermore, with PBL, the students
will be focused on the problem, the issue that will be
faced in professional world.1,3,12
Snoeckz reported that PBL system has been
implemented in Maastricht University, Holland, since
1974.13 Physiology subject is learned from the first year
to fourth year. He confessed that with this method, the
students are persuade to explore the knowledge they
want to get according to their needs. This method is
very suitable for the motivated and highly suspicious
students, however there are also some students that
complaint the uncertainty of the subjects that should
be learned. From some researches that comparing the
outcome of classic model (lectured-based) and PBL,
looks like this case is not easy because there are so
many factors that should be considered in measuring
the performance of a doctor.14 Even though some
educational researchers have been implementing
PBL model in graduate and post graduate in medicine
and health.15,16 It is important to be observed that PBL
needs an ideal references source from the regular and
virtual (internet) library.1,2,3,7 However, this has not had
achieved by FM-UKI, according to the students. The
tutors hold important role so that the tutorials go well
and reach the target of learning, even though in PBL
context, the tutors are not become the only source.
Because of the change of paradigm and action that
tutors are habitual to teach in front of the class, and
now more to be a facilitator and mentor, a routine
355
Table 2 The proportion between group 1, 2 (experiment), and 3 (control)
tutor training is needed, especially for the tutors who
are not competent in the scenario topic which is
discussed.1,8,17,18
Conclusion and Suggestion
The trial showed a significant difference between
experiment and control group in pre and post
test, furthermore in experiment group there is
a significant enhancement in pre and post test.
Performance evaluation of the students with OSCE
showed that the performance of the students in
Anamnesis and Writing Prescription are good,
however in VCT, IO, and ARV Counseling are need
more attention. The students are more confindent
356
if deal with HIV/AIDS cases and recommending this
block (subject) for other students.
In general, the students are satisfied of this block
trials. However, the infrastructure support needs to
be improved (internet, library, study room, AVA) and
the students suggest more hospital excursion.
Acknowledgements
Author would like to acknowledge Indonesia HIV & AIDS
Prevention and Care Project II – AusAid that has helped
the process of making and organizing this modul trial
as a part of Medical Staff and Teacher RSU FM-UKI and
FM-UKI Capacity Improvement Project, Jakarta.
Annotated Bibliography by Year
Annotated Bibliography
Full reports are available on the enclosed CD
Full repor ts are available on the enclosed CD
357
I. 1995-2000
AIDS Knowledge and Risk Behaviors among Domestic Clients of Female Sex Workers in Bali, Indonesia
Authors: Peter Fajans, Kathleen Ford and Dewa Nyoman Wirawan
Study Site: Bali
Institutions: University of Michigan, USA, and Udayana University, Indonesia
Written in English
Year 1995
Published in: Soc Sci Med. 1995 Aug;41(3):409-17
This study investigated AIDS and STD knowledge, risk behaviors and condom use among clients of female
commercial sex workers in Bali, Indonesia. Although the socioeconomic status of these clients was diverse,
they all tended to have low levels of knowledge concerning HIV and STD transmission, means of prevention,
multiple sexual partners, low frequency of condom use, and experience with frequent STDs. Although HIV
sero-prevalence rates are currently low in Indonesia, clients of CSWs are at high risk of HIV transmission.
Interventions to prevent the spread of the HIV virus must be targeted not only to CSWs, but also to their clients.
These interventions should include educational activities concerning AIDS/STD transmission and prevention,
condom promotion, efforts to improve condom availability, and activities to strengthen the health sectors’ STD
diagnosis and treatment capabilities.
Douching In Pregnant Women and Sexually Transmitted Diseases In Surabaya, Indonesia.
Authors: M.R. Joesoef, MD, H. Sumampouw, MD, M. Linnan, MD, S. Schmid, PhD, A. Idajadi, MD, and M,E. St.
Louis, MD
Study Site: Surabaya
Institutions: Centers for Disease Control and Prevention, USA, University of Airlangga, Indonesia
Written in English
Year 1996, Published in: Am J Obstet Gynecol. 1996 Jan;174(1 Pt 1):115-9
Objective of this study is to investigate the association between douching (douching agents and timing) and
sexually transmitted diseases (STDs). A cross-sectional survey of STDs and habits of vaginal douching was
performed on 599 pregnant women who visited a prenatal clinic in Surabaya, Indonesia. Of the 599 pregnant
women, 19.2% had at least one STD (gonorrhea, chlamydia, syphilis, trichomoniasis, or herpes simplex virus-2).
Most women had douched with water (19%) or water and soap (63%) at least once in the preceding month.
The author concluded that significant association between presence of STD and douching habits (douching
with betel leaf, commercial agents, or water and soap) exists.
The Perception of High School Teachers about HIV/AIDS : A Preliminary Study in Bogor District, 1996.
(Persepsi Guru Sekolah Menengah tentang HIV/AIDS: Suatu Studi Pendahuluan di Wilayah Kabupaten Bogor,
1996)
Authors: Yudarini Priotomo, Tirta Yenti, Tri Yunis Miko
Study Site: West Java, Indonesia
Institution: Health Research Center, University of Indonesia (PPK UI)
A Project Report Funded by Directorate for High Education, Ministry of Culture & Education
Written in Bahasa
Year 1996
It is a descriptive research with cross sectional design to explore perception of junior and senior high school
teachers about HIV/AIDS. It showed that knowledge about HIV/AIDS is generally quite impressive. However,
discrimination emerges when question on “what is your acceptance when a student or a teacher who is infected
by HIV still wants to continue his/her education or teaching” arose; responses showed distinct discrimination.
Development of Appropriate IEC Modules with Key Messages on Reproductive Health and HIV/AIDS Risk for
Islamic Religious Organization Groups
Author: Nick G Dharmaputra
Study Site: Indonesia
359
A Project Report Funded by AIDSCAP/FHI
Written in English
Year 1997
This study has focused on the development and testing of an appropriate prototype Reproductive Health
(RH) module for Moslem adolescents aged 14-21 years. The module also includes manuals for implementing
community education on the RH materials with suggestions on ways to insert modifications of IEC in
accordance to local socio-cultural factors. However, the most important step towards the development of this
intellectual product is the creation of common perception among the two major Islamic group themselves
regarding appropriate Islamic messages on: the importance of family and religious values in RH issues and to
avoid premarital sex; the understanding of male/female reproductive organs, the sanctity of pregnancy and
birth, family planning, recognition of social and sexual deviations, sexually transmitted diseases, including the
dangers of HIV/AIDS epidemic, and other current and relevant adolescent and delinquency issues.
Operational Assessment of Institutional Responses to HIV/AIDS in Indonesia
Authors: Nick G Dharmaputra, Budi Utomo, Sandi Iljanto
Study Site: National
A Project Report Funded by Family Health International (FHI/ASA Project)
Written in English
Year 1997
This report aims to provide an operational assessment of the National AIDS Strategy (NAS) and the various
responses towards the HIV/AIDS campaigns in Indonesia. The framework of the assessment follows the salient
structured element of NAS. Field observations indicate that regulations and ideal structures of the NAS have
been established, but in practice the operational priorities of the AIDS Commissions as a distinct sectoral
agency has not yet clearly occurred in terms of continual staff support, scope of work, equipment and funding.
There is still lack of a single unifying voice among key decision makers at both central and regional levels with
regard to HIV/AIDS issues.
Hindering Factors of Family in Accepting HIV-infected Relative (Highlights on Cultural Aspect, Lack of Knowledge, and Relative Bound in a Family)
(Faktor-faktor yang Menghambat Keluarga Dalam Menerima Salah Seorang Anggotanya yang Terinfeksi HIV/AIDS (Penekanan pada Masalah Budaya, Ketimpangan Pengetahuan dan Keterikatan Hubungan dalam Keluarga))
Author: Dede Shinta S Sudono
Study Site: Jakarta, Indonesia
Institution: School of Social & Political Sciences, University of Indonesia (FISIP UI)
Bachelor Thesis, 1997
Written in Bahasa
This study tried to depict factors that hinder family in accepting their member (relative) who is infected by HIV/
AIDS. Using in-depth interview, the author tried to obtain information from the family and doctors, those who
are providing care to the HIV-infected person. Literature study has also been conducted for secondary data;
upholding the information given by family and doctors. Based on the result, factors that hinder family from
caring are lack of knowledge, low-income family, loose family-hood, and stigma by the neighbors.
The Hidden Dimension: Sexuality and Responding To The Threat Of HIV/AIDS In South Sulawesi, Indonesia
Authors: Nicholas Ford, Kemal Siregar, Rusli Ngatimin and Alimin Maidin
Study Site: South Sulawesi
Institutions: University of Exeter, UK, University of Indonesia, Indonesia, and University of Hasanuddin,
Indonesia
Written in English
Year 1997
Published in Health Place. 1997 Dec;3(4):249-258.
Several Asian countries (notably India, Thailand and Burma) are now estimated to have substantial numbers
of HIV-infected persons. The critical interacting factors which shape the HIV/AIDS epidemic in specific settings
are the sexual and injecting drug using practices and the governmental and societal responses to the threat of
AIDS. This paper explored these factors in South Sulawesi in Eastern Indonesia. It presented recent quantitative
360
STD/HIV Risk Behavioral Surveillance Surveys 1996, 1997: Results from North Jakarta, Surabaya, and Manado.
Authors: Budi Utomo, Nick G Dharmaputra, Stephen Mills, John Moran
Study Site: Jakarta, Surabaya, and Manado, Indonesia
A Project Report Funded by HAPP/FHI
Written in English
Year 1998
Both Behavioral Surveillance Surveys (BSS) of 1996 and 1997 used cross sectional design to meet the objectives
of the surveys. Data obtained from the surveys indicated that high percentage of respondents had ever heard
of HIV/AIDS among all target groups. Yet, there was low level of information on the modes of its transmission
and prevention existed. Based on the obtained data, it recommends that there was an urgent need to maintain
and expand regular sentinel surveillance of sexually high-risk groups’ behavior pattern.
Executive Summary: STD/HIV Risk Behavioral Surveiilance Survey 1996 and 1997: Result from the Cities of
North Jakarta, Surabaya, and Manado
Authors: Budi Utomo, Nick G Dharmaputra, Stephen Mills, John Moran
Study Site: North Jakarta, Surabaya, and Manado, Indonesia
Written in English
Year 1998
This report presents selected baseline measures of STI/HIV risk behavior among selected groups of population
in three seaport cities in eastern part of Indonesia. Both Behavioral Surveillance Surveys (BSS) 1996 and 1997
used a cross sectional design with a structured questionnaire. Self-reported sexual behavior data related to
STI/HIV risks collected at the same designated sampling sites from the respondents. The result of both surveys
showed little change in reported risk behavior of the target groups, indicating that intervention programs have
not yet been widespread effectively to affect the population groups.
Outreach Method as A Tool in Reaching The Youth from Slum Areas for Spreading HIV Information (A Review
Towards Outreach Model Done by Mitra Indonesia Foundation in Jaringan Sub-district)
(Penggunaan Metode Outreach Untuk Menjangkau Kaum Muda di Kampung Miskin/Kumuh dalam Rangka Penyebaran Informasi HIV/AIDS (Suatu Telaah Mengenai Metode Outreach yang Dilakukan oleh Yayasan Mitra Indonesia
di Wilayah Kelurahan Penjaringan)
Author: Bagus Aryo
Written in Bahasa
Due to the increasing number of rural people moving to urban areas, new slum areas appear and are increasing
rapidly. In these areas, people with low socio-economic status have low access to health information and care
services. Thus, study recommends that by having outreach program to reach young people in these areas,
providing them with knowledge through peer approach could help in developing healthy behaviours among
the young people.
STD/HIV Risk Behavioral Surveillance Surveys 1996, 1997, and 1998: Results from Cities of Jakarta, Surabaya,
and Manado
Authors: Budi Utomo, Nick G Dharmaputra, Adji V Hakim, Stephen Mills, John Moran
Study Site: Jakarta, Surabaya, and Manado, Indonesia
Written in English
Year 1999
361
and qualitative research findings on sexual culture, AIDS awareness and public health response in relation to
the distinctive features of S. Sulawesi’s geographical and socio-cultural setting.
This study presents comparative baseline measures of STD/HIV risk behavior among selected population
group in 3 seaport cities of Indonesia. The measures were based on data generated from three behavioral
surveillance surveys (BSS) 1996, 1997, and 1998. Results of the three surveys showed that knowledge, but not
practices, improved across all the target groups. The percentage of those who reported ever heard of HIV/AIDS
was relatively high (above 90%) and increased across most target groups. Apart of that, there was a continued
high percentage of the target groups with misconception on modes of HIV/AIDS transmission and preventions
(above 50%).
STD/HIV Risk Behavioral Surveillance Surveys, in Bali, Kupang, and Ujung Pandang, 1998
Authors: Budi Utomo, Nick G Dharmaputra, Adji V Hakim, Iwu D Utomo, Abby Ruddick
Study Site: Bali, Kupang, and Ujung Pandang, Indonesia
A Project Report Funded by IHPCP-AusAID
Written in English
Year 1999
This report presents selected baseline of STD/HIV risk behaviors among selected groups of population in three
seaport cities in eastern part of Indonesia. The samples includes 600 sailors, 602 interstate truckers, 600 urban
public transport drivers, 250 direct clients of commercial sex workers (CSW), 693 CSWs, 170 homosexuals, and
180 transvestites. The result of this survey showed that knowledge about HIV, among surveyed population was
good. Nevertheless, some misconception regarding the modes of prevention did prevail.
Female commercial sex workers in Kramat Tunggak, Jakarta, Indonesia
Author: Endang R. Sedyaningsih-Mamahit
Study Site: Jakarta
Institution: National Institute of Health Research & Development, Jakarta, Indonesia
Written in English
Year 1999
Published in Soc Sci Med. 1999 Oct;49(8):1101-14
More than 60% of the reported HIV-positive cases in Indonesia can be attributed to heterosexual transmission;
therefore, by the nature of their work, female commercial sex workers (FCSWs) constitute one of the
communities at risk. No meaningful or effective STD/HIV prevention programs for FCSWs can be planned if
there is no contextual understanding of these women as persons, the nature and the risks of their job and their
relations with their clients and managers. Interweaving qualitative and quantitative methods, this research
investigates the FCSWs in an `formal’ brothel complex in Jakarta, Indonesia. Results of this study give insights of
four typologies of FCSWs observed in Kramat Tunggak. The personal, professional, social and other differences
which influenced the women into full-time sex work and affected their willingness and ability to engage in
healthy and protective behaviors, are presented.
Socio-demographic Profile of People Living with HIV in Indonesia: Some Prominent Issues from Rapid Assessment in Bali and Surabaya.
(Profil Sosio-Demografis Orang Hidup dengan HIV/AIDS (ODHA) di Indonesia: Beberapa Isu Penting dari
Hasil Kajian Cepat di Surabaya dan Bali)
Authors: Sri Sunarti Purwaningsih, Widayatun, Fadjri Alihar, Djoko Hartono
Study Site: National, Indonesia
Institution: Center for Demography & Man Power Research - Indonesian Institute of Science (PPT-LIPI)
Written in Bahasa
Year 2000
Considering the lack of adequate data about PLHIV with the Ministry of Health of Indonesia, this study tried
to complete the profile of PLHIV in Indonesia. The profile, it was expected that people, particularly decisionmaking level, will increase awareness about the epidemic.. This epidemic wass not just affecting people in their
reproductive ages; it also affected wider section of communities.
Rapid Assessment and Response of IDUs in Kupang City
(Pelanggan Pekerja Seks di Kota Kupang)
Authors: Primus Lake, Eman R Goring, Ady Lamury, Agus Agun, Yulius Detamauk
Study Site: NTT, Indonesia
Institution: Bina Insan Mandiri Foundation
362
The study showed that 90% of IDUs in Kupang City had knowledge about HIV transmission. Only a small
percentage of them had myths that HIV can be transmitted through kissing, tongue-licking, from the seat of
HIV-infected person, or using the towel or clothes of PLHIV. One of the interviews depicted IDU’s opinion for
health workers that when communicating information with targeted groups, they should use understandable
language.
II. 2001-2003
Findings of the Behavioral Surveillance Survey (BSS 1996-2000) among Female Commercial Sex Workers and
Adult Male Respondents.
Authors: Budi Utomo, Nick G Dharmaputra
Study Site: National, Indonesia
A Project Report Funded by HAPP/USAID
Written in English
Year 2001
The first baseline STI/HIV Risk Behavioral Sentinel Survey (BSS) was conducted by the Center for Health
Research, University of Indonesia (PPK UI) in late 1996. As a follow up to the successful outcome of BSS 1996
and 1997, and the continued need to generate comparative time-series data, the third, fourth, and fifth rounds
of BSS were implemented by 1999.
Analysis of trends across the five waves of data collection specifically among female sex workers (FSW) and adult
males shows these facts: (i) there was high percentages of respondents in all the surveyed sub-populations who
had heard of HIV/AIDS, (ii) male respondents and FSW showed increasing knowledge about appropriate ways
to prevent HIV transmission over the years, (iii) level of knowledge of condom had increased, (iv) knowledge
of STIs has remained low, (v) percent of male who had sex with FSW increased over survey years, (vi) reported
condom use in last sex with FSW among male respondents showed an increase, and (vii) there were still high
number of male respondents and FSW who wanted to self-treat STIs.
High rate of bacterial vaginosis among women with intrauterine devices in Manado, Indonesia
Authors: M.R. Joesoef, A. Karundeng, C. Runtupalit, J.S. Moran, J.S. Lewis, C.A. Ryan
Study Site: Manado
Institutions: Centers for Disease Control and Prevention, USA, and Bahagia Harapan Kita Foundation,
Manado, Indonesia
Written in English
Year 2001
Published in Contraception. 2001 Sep;64(3):169-72
Recent studies reported that bacterial vaginosis (BV) might enhance the acquisition and transmission of HIV.
BV is also associated with an increased risk of pelvic inflammatory disease, a disease also associated with
intrauterine device (IUD) insertion. To measure the magnitude of this problem, the authors conducted a
prevalence survey of BV and sexually transmitted diseases among all patients attending a family planning clinic
in Manado from May to July 1999. Of 357 patients, 116 (32.5%) had BV, 83 (23.3%) had trichomoniasis, 9 (2.5%)
had chlamydia, and 8 (2.2%) had gonorrhea. The prevalence of STD was similar among users of all types of
contraception. However, BV was more common among IUD users (47.2%) than among non-IUD users (29.9%).
This association persisted after controlling for age, education, ever had douching, and any STD. Because we
found that BV was associated with IUDs and that other studies reported that both BV and IUDs were associated
with pelvic inflammatory disease, a Gram stain evaluation of BV may be considered prior to IUD insertion.
363
Written in Bahasa
Year 2000
The Bali STD/AIDS study: association between vaginal hygiene practices and STDs among sex workers
Authors: Barbara D Reed, Kathleen Ford, Dewa N Wirawan
Study Site: Bali
Institutions: University of Michigan, USA, and Kerti Praja Foundation, Bali, Indonesia
Written in English
Year 2001
Published in Sex Transm Infect. 2001 Feb;77(1):46-52.
Low priced commercial sex workers (CSWs) participated in the Bali STD/AIDS Study, a 3 year educational project
evaluating the effect of education on the subsequent use of condoms and the prevalence of STDs and AIDS.
This study tried to assess the association between genital cleansing practices and the prevalence of sexually
transmitted diseases and of sexual health knowledge among female sex workers in Bali, Indonesia. Using
structured interviews, genital evaluation, laboratory evaluation for STDs, and treatment were performed. There
were 625 female sex workers evaluated between May and July 1998.
Commercial sex workers in low priced brothels in Bali had a high rate of genital infections, with lower rates of
viral compared with bacterial infections. Genital cleansers, on a daily or after each intercourse schedule, were
used routinely. Although genital cleansing after each intercourse was associated with fewer genital symptoms,
the prevalence of STDs did not differ significantly based on this frequency.
Rapid Assessment and Response of IDUs in Kupang City
(Rapid Assessment and Response Penggunaan Narkoba Suntikan (IDU) di Kota Kupang)
Author: Primus Lake
Study Site: NTT, Indonesia
Institution: Bina Insan Mandiri Foundation
Written in Bahasa
Year 2001
There were 80 IDUs included in this study. Major motive of the respondents for using drugs was to satisfy their
curiosity about the feel of using it, afraid of being marked as an outdated person, pressure from peer group if
not using it, to control stress, and to increase their aggressiveness. Reasons for these people to choose injecting
drugs were to adopt peer model who were already using it, drug action was faster, cheaper than other drugs,
and more pleasure was obtained when using injecting mode.
Outreach Method for Injecting Drug Users as A Behavioral Change Intervention in Preventing The Spread of HIV/AIDS
(Metode Outreach Terhadap Injecting Drug Users Suatu Upaya Perubahan Perilaku Dalam Pencegahan Penyebaran HIV/AIDS)
Author: Ericsson Firdaus
Written in Bahasa
The author explored the impact of outreach method for IDUs to bring health services closer to IDUs in reducing
the adverse effects of injecting drugs. The conclusion was that outreach workers needed to provide IDUs with clear
information on how HIV was being transmitted among them. Outreach workers must be able to stimulate this
group to understand the risk they are taking by using injecting drugs and to promote harm reduction among IDUs.
The Bali STD/AIDS Study: Evaluation of an Intervention for Sex Workers
Authors: Kathleen Ford, PhD, Dewa Nyoman Wirawan, MD, MPH, Barbara D. Reed, MD, MPH, Partha
Muliawan, MD, MPH, and Robert Wolfe, PhD
Study Site: Bali
Institutions: University of Michigan, USA, and Kerti Praja Foundation, Bali, Indonesia
Written in English
Year 2002
Published in Sex Transm Dis. 2002 Jan;29(1):50-8.
364
Protection of law for HIV-infected IDUs: The need for Positive Law in Indonesia
(Perlindungan Hukum Terhadap Penyalahguna Narkotika yang Tertular HIV Menurut Hukum Positif di Indonesia)
Author: Naniek Suwarni
Study Site: Cpinang Prison and Cipto Mangunkusumo Hospital, Jakarta, Indonesia
Institution: Law School, University of Islam Jakarta (FH Univ Islam Jakarta)
Written in Bahasa
The objective of this study was to estimate the number of Intravenous Drug Users (IDU) who were at risk of
HIV transmission through sharing of unsterile needles. Both qualitative and quantitative methods were used
to strengthen the study. It focused on HIV positive IDUs in Cipto Mangunkusomo Hospital (RSCM) and inmates
of Cipinang prison.
The study recommended that a positive law of human rights for IDU for preventing HIV transmission among
them is essential.
A Survey of Teenagers in Papua, Indonesia, 2003: Qualitative Baseline Data Collection for Intervention Aimed
at Reducing HIV Vulnerability of Young People in Papua
Authors: Rita Damayanti, Nick G Dharmaputra
Study Site: Papua, Indonesia
A Project Report Funded by UNICEF
Written in English
Year 2003
This survey was conducted with the aim of reducing HIV vulnerability of young people in Papua province. In
this qualitative survey, it was planned that from 10 selected schools in each district, 2 schools were selected. In
each school there were 2 focus group discussions (FGDs); each with 8 boys and 8 girls randomly selected with
their informed consent.
Data showed that Papuan teenagers, in general, (around 70%) were already aware about reproductive health
issues. Yet, there were more than 30% teenagers who were still not fully aware of physical development for
their age. Survey data also shows that many students were still unaware of biological consequences when they
engaged in sex.
Process of Knowledge, Transition and Adoption towards Reducing the risk of HIV/AIDS among IDUs in
Cimanggis District
(Proses Pengalihan Pengetahuan dan Pengadopsian Pengurangan Risiko HIV/AIDS di Kalangan IDU di Cimanggis)
Author: Ahmad Caesar
Study Site: Depok, Indonesia
Written in Bahasa
This qualitative study was aimed at how far the knowledge of risky behaviors was perceived by an IDU. The result
showed that injecting and sex behaviors of individual IDUs varied, though they received same information on
reducing HIV risky behaviors from the same source of information. That depiction was influenced by variety of
experiences of the respondents.
365
Sex work has been an important factor in the spread of HIV infection in Asia. Interventions need to be developed to
reduce the risk of transmission of sexually transmitted infections in this area. The goal of the interventions is to educate
female sex workers about sexually transmitted infections and assess the impact of the educational intervention. A
total of 1,586 women participated in at least one evaluation round. The authors concluded that planners of HIV/STD
intervention programs for sex workers need to consider the mobility of the sex worker population. Interventions
combining behavioral and medical approaches can contribute to prevention of these diseases.
Peer Education Method to Provide Information to Youth in Hang-Out Places: A Review on Peer Education Method Drop In Center Cijantung (Die J) by Pelita Ilmu Foundation in Cijantung Mal, East Jakarta
(Metode Peer Education Sebagai Upaya Pemberian Informasi HIV/AIDS pada Remaja di Pusar Keramaian: Sebuah Kajian
Metode Peer Education Drop In Center Cijantung (Die J) Yayasan Pelita Ilmu di Mal Cijantung Jakarta Timur)
Author: Djadjat Sudradjat
Written in Bahasa
Peer education method can be used as one of the many ways to prevent HIV spreading among the youth,
especially those who spent most of their time in hangout places, like malls. The author wanted to know the
process of knowledge transfer to this group through this method. The findings showed that knowledge
transfer about HIV/AIDS helped bring significant changes among this targeted young people. The youth had
understood transmission of HIV, the testing for HIV, and the prevention of HIV. They showed positive attitude
by supporting the prevention programs.
Sexually Transmitted Infections among Female Sex Workers in Kupang, Indonesia: Searching for a Screening
Algorithm to Detect Cervical Gonococcal and Chlamydial Infections
Authors: Stephen C. Davies, MM(VEN.), FACSHP, Brad Otto, BA, Sutaryo Partohudoyo, MD, MPH, V. A. M. A.
Chrisnadarmani, MD, MPH, Graham A. Neilsen, MM (Sexual Health), FACSHP, Laura Ciaffi, MD, MPH, Jane
Patten, MPH, Ehe T. Samson, MD, SPPK, and I Nyoman Sutama, MD, SPKK
Study Site: Kupang
Institutions: IHPCP, Indonesia; Macfarlane Burnet Institute for Medical
Research and Public Health,, Australia; Medecins Sans Frontieres, Belgium; and Professor Dr Yohannes
Provincial Hospital, Kupang, Indonesia
Written in English
Year 2003
Published in Sex Transm Dis. 2003 Sep;30(9):671-9.
Notifications of HIV infection in Indonesia are increasing, but there are few data on other sexually transmitted
infections (STIs), especially in the eastern islands of Indonesia. The authors aimed to measure the prevalence of
STIs among female sex workers (FSWs) in Kupang, West Timor, and to develop screening algorithms to detect
cervical infections with Neisseria gonorrhoeae and/or Chlamydia trachomatis (NG/CT). A total of 288 FSW
participated in the study. The result showed that prevalence of N gonorrhoeae infection was 31%, that of C.
trachomatis infection was 24%, that of Trichomonas vaginalis infection was 5%, and that of syphilis was 13%.
No case of HIV infection was detected. Few women had symptoms of STI.
Although several of the generated algorithms may be useful in the absence of simple, accurate, affordable
diagnostic tests, the high rates of STIs in this population could justify a more aggressive strategy incorporating
periodic presumptive treatment to rapidly reduce the prevalence.
A Survey of Teenagers in Papua, Indonesia, 2003: Quantitative Baseline Data Collection for Intervention Aimed
at Reducing HIV Vulnerability of Young People in Papua
Authors: Rita Damayanti, Nick G Dharmaputra
Study Site: Papua, Indonesia
A Project Report Funded by UNICEF
Written in English
Year 2003
This survey is conducted aiming at reducing HIV vulnerability to young people in Papua province was conducted
by PPK UI with the support of UNICEF. This student quantitative survey used cross sectional survey with two
stages cluster sampling under the proportionate probability sampling method. Total sample for this survey
was 2,100 students.
366
III. 2004-2006
Sex Work for Living: A Phenomenon of Girl Trafficking In South Sumatera
(Melacur Demi Hidup: Fenomena Perdagangan Anak Perempuan di Palembang)
Author: Mulyanto
Study Site: South Sumatera, Indonesia
Institution: Research Center on Population and Policy, University of Gadjah Mada (PSKK UGM)
A Project Report Funded by Ford Foundation
Written in Bahasa
Year 2004
This study was focused on trafficking of girls for sex work in Palembang and other cities in South Sumatera. This
is not yet a public issue simply because the trafficking in girls is merely the access to prostitution. The study
encountered 29 trafficked girls who were placed to four different lokalisasi (prostitution settlements). The
traffickers were mostly those who had close relationship with the girls such as a boyfriend, an acquaintance,
relative(s), or even their own parents. The recruitment was based on deception such as false information about
work, or relatively attractive high wages. Also debt bondage was used for some girls because they were required
to pay some amount of money to cover their travel, accommodation and meal cost during the recruitment. Yet,
they were also exposed to physical, psychological, and sexual violence in the process of recruitment and kept in
brothels.
A Tragedy behind Amoi Trafficking in Singkawang
(Tragedi Perdagangan Amoi Singkawang)
Authors: Agus Sikwan, Maria Rosarie Harni Triastuti
Study Site: Kalimantan

Indonesia: HIV/AIDS Research Inventory, 1995-2009

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