Factors Influencing Brothel-Based Female Sex Workers ... - UIC Indigo

Factors Influencing Brothel-Based Female Sex Workers’ Self-Perceived Risk For

HIV Infection in Surabaya

BY

SAMSRIYANINGSIH HANDAYANI M.D., Airlangga University, 1990

M.Kes., Airlangga University, 1999 M.Ed., Monash University, 2008

THESIS

Submitted as partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Health Sciences

in the Graduate College of the University of Illinois at Chicago, 2014

Chicago, Illinois

Defense Committee: Judith A. Levy, Chair and Advisor, Division of Health Policy & Administration Sally Freels, Division of Epidemiology and Biostatistics Ronald Hershow, Division of Epidemiology and Biostatistics Timothy Johnson, Survey Research Laboratory Chyvette Williams

This dissertation is dedicated to my late mother, Sri Trembini, who devoted her time to teach me basic knowledge so that I could pass my one-month first grade and to accompany me as I spent my nights studying. Any to my late father, Sama’oen who worked two shifts so that his children could focus on their studies.

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ACKNOWLEDGEMENTS

I would like to thank my dissertation committee – Drs. Judith a. Levy, Ronald Hershow,

Sally Freels, Timothy Johnson and Chyvette Williams – for their tireless support, assistance and

constructive critiques. Their guidance helped me achieve my research goals and enrich my

research experience.

I would like to acknowledge the United States Agency for International Development for

providing a scholarship that made my degree attainment possible.

Dr. Judith Levy, who chairs the University of Illinois at Chicago AIDS International

Training and Research Program (UIC-AITRP), has also greatly contributed to this

accomplishment by opening opportunities for my research skills development through various

seminars and trainings, and by providing substantial research funding in collaboration with the

USAID. She also proudly showed me around the 7th floor offices at the UIC School of Public

Health building and knocked on almost every door to announce the beginning of my PhD

candidacy. This touching moment caused a profound effect on me and boosted my spirit to work

harder. I would like to express my highest appreciation to her.

My sabbatical leave of study would not be possible without support from Professor Dr.

Fasichul Lisan, the President of Airlangga University, which is the Institution where I work. I

would like to thank him for his enormous support.

I would like to express my gratitude to Professor Dr. Muhammad Amin, the previous

Dean of the School of Medicine at Airlangga University, for his encouragement to apply for a

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USAID scholarship for doctoral study, and also to Professor Dr. Agung Pranoto, the current

Dean of the School of Medicine at Airlangga University, for his continual support.

I would also like to thank Dr. Sunarjo and Dr. Djohar Nuswantoro, who are the previous

and current Heads of Public Health and preventive Medicine, Department of the School of

Medicine at Airlangga University, for their unwavering support in pursuing the study and

completion of my HIV project at UIC.

A number of individuals at the data collection site in Surabaya, Indonesia, were

extremely helpful and I would like to thank them as well. They include: Dr. Ivan Rahmatullah, my

medical students, the non-governmental organizations working with sex workers (Yayasan Abdi

Asih, Yayasan Genta, Yayasan Hotline Surabaya), and my study participants (the female

workers of the six brothel compounds in Surabaya).

My sincere gratitude also goes to UIC-AITRP fellow students for having been my

discussion partners and for sharing the office with me for four years; and to the UIC-AITRP staff

whose assistance was invaluable.

My sister, Samsriyati Nugrahani, and her family, insisted that I visit them in the USA and

capture the spirit of advanced learning from a university environment. Years later, the spirit has

influenced my decision to study in the USA. I would like to thank them as well.

My brother, Samsriyono Nugroho, has always been my rival, as well as, supporter in

study. He and his family offered their home, love and assistance when I was in Indonesia, for

which I would like to thank them.

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I would also like to thank my cousin, Gunawan Wignyosumarto, and his family for

providing their home and assistance when I was preparing my preliminary examinations and

collecting data in Surabaya. His daughter, Rani Widya Pramesthi, helped me copy and bind

questionnaires and prepare interview logistics for the following day.

My cousin and her husband, Lusia Katrin Prasetyawati and Antonius Sugiarto, have

always been available to listen to my difficulties and have also offered a home to visit when we

were in the US. I would like to thank them for their warm acceptance.

Dr. Sri Setiyani, Dr. Suwarsi Retnowati, Dr. Sawitri Retno Hadiati, Dr. Sulistiawati, Dr.

Linda Dewanti, and other colleagues in Surabaya have supported me through various ways. I

would like to thank them all.

SH

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TABLE OF CONTENTS

CHAPTER PAGE I. INTRODUCTION……………………………………………………………. 1 A. The AIDS Epidemic in Indonesia………………………………. 2 1. Indonesia – an overview………………………………… 2 2. Epidemiology HIV in Indonesia………………………… 4 3. Geographical Distribution………………………………. 5 4. Ethnic Groups Affected…………………………………. 7 5. Age Distribution………………………………………….. 7 6. Gender Distribution……………………………………… 8 7. Distribution of Risk Factors Associated with Vulnerability to HIV………………………………………. 9 8. Stigma, Gender Inequalities and Opposition Groups 10 9 Government Policy Response…………………………. 11 10. Public Health Response………………………………… 11 B. Sex Work and HIV Among Female Sex Workers in Indonesia 12 1. Commercial Sex Work in Indonesia…………………… 12 2. HIV Among Female Sex Workers in Indonesia……… 13 3. The Suspected Role of FSWs on Bridging the Epidemic to the General Population………………….. 4 C. Perception of Risk for HIV………………………………………. 5 1. The Concept of Perceived Risk………………………… 15 2. Assessment of Self-Perceived Risk for HIV………….. 16 3. Biases of Self-Perceived Risk Assessment………….. 16 4. Self-Perceived Risk for HIV in the General Population 18 5. Self-Perceived Risk for HIV Among FSWs.…………… 19 a. Demographic Characteristics………………….. 19 b. HIV Knowledge…………………………………… 20 c. Sex Work Experience……………………………. 22 d. Drug and Alcohol Use…………………………… 22 e. Perceived Knowledge…………………………… 22 f. Perceived Control……………………………….. 23 g. Protective Actions Against HIV Infection……. 24 h. Peer Support……………………………………… 25 i. Brothel Manager’s Support for HIV Prevention 25 j. NGO Support……………………………………… 27 k. Experience with STI/HIV Counselling and Testing Facilities………………………………….. 28 l. Sources of HIV Information……………………. 30 m. Social Stigma…………………………………….. 32 n. Other Infections………………………………….. 36 D. Theoretical Framework: The Social Ecological Model……… 36 E. Conceptual Framework………………………………………….. 40 F. Brothel Compounds Situation in Surabaya………………….. 42

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TABLE OF CONTENTS (continued)

II. METHODS………………………………………………………………….. 45 A. Aims of the Study……………………………………………….. 45 1. General Aim……………………………………………… 45 2. Specific Aim……………………………………………… 45 B. Hypotheses and Statistical Hypotheses…………………….. 45 1. The Main Hypotheses…………………………………... 45 2. Protective Actions………………………………………. 46 3. Intrapersonal Characteristics…………………………. 47 C. Setting……………………………………………………………… 47 D. Study Population Sampling Frame and Sample……………. 47 1. Study Population………………………………………… 47 2. Participant Eligibility……………………………………. 48 3. Recruitment………………………………………………. 48 4. Sample Size Calculation……………………………….. 49 a. Odds Ratio Calculation of the Indian Study Findings………………………………………….. 51 b. Po Calculation for FSWs in Surabaya………. 52 c. The Expected Fraction of FSWs Perceiving Themselves as Having Control Over Becoming HIV Infected………………………… 53 d. Sample Size Collection………………………… 53 5. Sampling Frame…………………………………………. 53 6. Final Sample……………………………………………… 54 E. Data Collection…………………………………………………… 54 1. Interviewer Training…………………………………….. 55 2. Pilot-Testing the Questionnaire………………………. 55 3. Data Collection Procedures…………………………… 56 4. Compensation…………………………………………… 56 F. Measures…………………………………………………………. 56 1. The Study Dependent Variables – Self-Perceived Risk for HIV………………………………………………. 56 2. The Study’s Main Independent Variable – Perceived Control Over Becoming Infected by HIV Infection… 56 3. Mediator-Protective Action……………………………. 57 4. Other Independent Variables…………………………. 57 G. Data Management……………………………………………….. 57 1. Data Cleaning, Transcription and Quality Control.. 57 2. Coding…………………………………………………….. 57 H. Data Analysis…………………………………………………….. 58 1. Multiple Imputations for Missing Values for Quantitative Analyses………………………………… 58 2. Hypothesis Training…………………………………… 58 I. Protection of Research Participants……………………….. 61

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TABLE OF CONTENTS (continued)

II. RESULTS…………………………………………………………………………. 62 A. Part A: Self-Perceived Risk for HIV (the Study’s Dependent Variable) Self-Perceived Risk for HIV……………………… 64 B. Part B: Intrapersonal Level Characteristics and Self- Perceived Risk for HIV………………………………………. 64 1. Demographic Characteristics of the Sample……. 64 2. Migration History…………………………………….. . 65 3. Sex Work Experience………………………………… 66 a. Length of Time Engaging in Commercial Sex Work Within the Brothel compounds From Which the Sample Was Recruited….. 66 b. FSWs Experience of Selling Sex Outside the Brothel Compound in the Last Twelve Months………………………………… 67 c. Engaging in Commercial Sex for Money in the Last Ramadan…………………………. 68 4. Alcohol Consumption and Drug Use……………… 68 5. Level of HIV Knowledge……………………………… 69 6. Self-Perceived Susceptibility to Disease…………. 69 a. Self-Perceived Risk for Different Diseases. 69 b. Associations Between Self-Perceived Risks for HIV and Other Diseases…………………. 70 7. Logistic Regressions Examining the Possible Association Between Intrapersonal Level Characteristics and Self-Perceived Risk for HIV…. 72 a. Bivariate Binary Logistic Regression Analyses of Self-Perceived Risk for HIV On Intrapersonal Characteristics………….. 73 b. Binary Logistic Multiple Regression Analyses of Self-Perceived Risk for HIV On Intrapersonal Characteristics…………… 75 C. Part C: Self-Perceived Control Over Becoming Infected By HIV……………………………………………………………. 76 1. The Distribution of Self-Perceived Control Over Becoming Infected by HIV…………………………… 76 2. Bivariate Binary Logistic Regressions of Self- Perceived Risk for HIV on Perceived Control Were Conducted for Each Variable Individually………… 78 3. Binary Logistic Multiple Regressions of Self- Perceived Risk for HIV on Perceived Control…….. 78 D. Part D: Examination of the Relationship Between Taking Protective Action and Self-Perceived Risk for HIV……….. 79 1. Distribution of Protective Actions Taken Against Acquiring HIV…………………………………………… 79 a. Frequency Distribution of Consistent Condom Use…………………………………… 79

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TABLE OF CONTENTS (continued) b. Bivariate Binary Logistic Regressions of Self-Perceived Risk for HIV on Condom Use. 81 2. Frequency Distribution of Methods Other Than Condom Use……………………………………………… 81 3. Bivariate Binary Logistic Regression of Self- Perceived Risk for HIV on Protective Actions Other Than Condom Use………………………………. 82 E. Part E: Binary Multiple Logistic Regressions Examining The Influence of All Significant Variable from all 3 Analytic Constructs (Intrapersonal Level, Perceived Control over Becoming Infected, and Protective Actions Taken) on Self-Perception of Risk for HIV………………………………… 83 F. Part F: The Model…………………………………………………. 85 1. Determining Mediation and Moderation……………… 85 a. The Effect of Experience of Working in Bar/Discotheque…………………………………. 86 b. Did Consistent Condom Use Moderate or Mediate the Effect of Self-Perceived Risk for Gonorrhea on Self-Perceived Risk for HIV…… 89 c. Did Consistent Condom Use Moderate or Mediate the Effect of Self-Perceived Risk for Syphilis on Self-Perceived Risk for HIV……… 91 2. The Final Model………………………………………….. 92 3. The Mathematical Model……………………………….. 93 G. Part G: Other Results – Clients’ Power………………………. 94 IV. DISCUSSIONS……………………………………………………………… 95 A. Self-Perceived Risk for HIV Among Women Working In the Brothel Compounds……………………………………… 95 B. The Influence of FSWs Intrapersonal Characteristics On Self-Perceived Risk for HIV Infection……………………. 95 1. Age………………………………………………………… 95 2. Education………………………………………………… 95 3. Home Provinces and Hometowns…………………… 96 4. Sex Work Experience…………………………………… 96 5. Alcohol Consumption and Drug Use………………… 97 6. Knowledge……………………………………………….. 97 7. Self-Perceived Susceptibility to Diseases………….. 97 8. Perceived Susceptibility of Peers…………………….. 99 C. Perceived Controls Over Becoming Infected by HIV And Self-Perceived Risk for HIV………………………………. 100 D. Protective Actions Against HIV and Self-Perceived Risk For HIV Infection…………………………………………………. 100 E. Limitations of the Study………………………………………… 100 F. Conclusion and Future Research Direction…………………. 101

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TABLE OF CONTENTS (continued) APPENDICES………………………………………………………………………………… 103 CITED LITERATURE………………………………………………………………………... 134 VITA……………………………………………………………………………………………. 141

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LIST OF TABLES TABLE PAGE

I. AIDS PREVALENCE PER 100,000 POPULATION BY PROVINCE IN 2010 ………………………………………………………………… 6

II. NEW AIDS CASE DISTRIBUTION BY AGE IN INDONESIA, 2005-2011 ………………………………………………………………. 8

III. NEW AIDS CASE DISTRIBUTION BY SEX IN INDONESIA, 2005-2011 ……………………………………………………………… 9

IV. AIDS CASE DISTRIBUTION BY RISK FACTORS IN INDONESIA, 2001-2005 AND 2006-2011 …………………………………………… 9

V. KNOWLEDGE ON HIV TRANSMISSION AMONG DIRECT FSWS IN INDONESIA IN 2002, 2004 AND 2007 …………………………………. 21

VI. CORRECT KNOWLEDGE ON HIV PREVENTION AMONG DIRECT

FSWS IN INDONESIA IN 2002, 2004 AND 2007 ……………………. 21

VII. MISCONCEPTION ON HIV TRANSMISSION AND PREVENTION, AND SELF-PERCEPTION ON RISK FOR HIV INFECTION AMONG DIRECT FSWS IN INDONESIA 2002, 2004 AND 2007 ……………… 23

VIII. CHARACTERISTICS BROTHEL COMPOUNDS OF JARAK, DOLLY,

DUPAK BANGUNSARI, TAMBAK ASRI, SEMEMI AND KLAKAH REJO, SURABAYA IN 2012 …………………………………………………….. 43

IX. PERCENTAGE OF MOBILE FSWS ACCORDING TO THE DEGREE OF CONGRUENCE BETWEEN HIV RISK PERCEPTION AT INTERVIEW AND PRIOR CONDOM USE BEHAVIOR WITH OCCASIONAL CLIENTS IN INDIA ……………………………………………………… 51

X. HIV RISK PERCEPTION DISTRIBUTION BY CONDOM USE CONSISTENCY …………………………………………………………… 51

XI. SELECT IBBS 2007 DATA FOR DIRECT FSW (BROTHEL- AND STREET-BASED) IN SURABAYA ……………………………………… 52

XII. SUMMARY OF THE DEPENDENT VARIABLE, INDEPENDENT VARIABLES, THEIR LEVELS OF MEASUREMENT AND THE MISSING DATA ……………………………………………………….. 60

XIII. DISTRIBUTION OF SELF-PERCEIVED RISK FOR HIV (N=155) … 64

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LIST OF TABLES

TABLE PAGE

XIV. DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS

WORKING IN THE BROTHEL COMPOUNDS OF DUPAK BANGUNSARI, TAMBAK ASRI, SEMEMI, KLAKAH REJO, DOLLY AND JARAK, SURABAYA (N=155) ……………………….. 65

XV. DISTRIBUTION OF BROTHEL-BASED FSWS’ HOME PROVINCES AND URBAN VERSUS RURAL HOME TOWNS (N=155) ………………………………………………………. 66

XVI. LENGTH OF TIME ENGAGING IN COMMERCIAL SEX IN THE RECRUITMENT COMPOUNDS ……………………………….. 67

XVII. DISTRIBUTION OF FSWS’ WORKPLACE IN THE LAST TWELVE MONTHS (N=155) …………………………………………. 67

XVIII. ALCOHOL DRINKING BEFORE SEX IN THE LAST THREE MONTHS ……………………………………………………… 68

XIX. FSWS’ LEVEL OF HIV KNOWLEDGE …………………………….. 69 XX. COMPARISON OF SELF-PERCEIVED RISK FOR

5 INFECTIONS................................................................................. 70

XXI. RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSION ANALYSES OF SELF-PERCEIVED RISK FOR HIV ON SELF- PERCEIVED RISK FOR OTHER INFECTIONS ……………………… 71

XXII. RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSION ANALYSES OF SELF-PERCEIVED RISK FOR HIV (NUNLIKELY = 78 NLIKELY =70) ON FSWS’ PERCEPTION OF PEER’S RISK FOR HIV ……………………………………………….. 72

XXIII. RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV (NUNLIKELY=49, NLIKELY=106, UNLIKELY AS REFERENCE) ON INTRAPERSONAL CHARACTERISTICS OTHER THAN SELF-PERCEIVED RISK FOR INFECTIONS……………………………………………………….. 74

XXIV. BINARY LOGISTIC MULTIPLE REGRESSIONS OF SELF- PERCEIVED RISK FOR HIV (NUNLIKELY=49, NLIKELY=106, UNLIKELY AS REFERENCE) ON INTRAPERSONAL CHARACTERISTICS …………………………………………………… 76

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LIST OF TABLES TABLE PAGE

XXV. DISTRIBUTION OF PERCEIVED-CONTROL OVER BECOMING INFECTED BY HIV AMONG RESPONDING FSWS …………………………………………………. . 77

XXVI. RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSION OF SELF-PERCEIVED RISK FOR HIV ON PERCEIVED CONTROL ……………………………………………………………… 78

XXVII. RESULTS OF BINARY LOGISTIC MULTIPLE REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV ON PERCEIVED CONTROL (NUNLIKELY =81, NLIKELY =74, UNLIKELY AS REFERENCE) … 79

XXVIII. CONSISTENT CONDOM USE AMONG TOTAL CLIENTS IN THE LAST 7 DAYS …………………………………………………………… 80

XXIX. CONDOM USE AMONG NEW CLIENTS IN THE LAST 30 DAYS…. 80 XXX. RESULTS OF BIVARIATE BINARY LOGISTIC REGRESSIONS

OF SELF-PERCEIVED RISK FOR HIV (NUNLIKELY=81, NLIKELY=74, UNLIKELY AS REFERENCE) ON CONDOM USE …………………………………………………………. 81

XXXI. DISTRIBUTION OF PROTECTIVE ACTIONS OTHER THAN CONDOM USE TAKEN IN THE LAST 30 DAYS AGAINST HIV INFECTION ……………………………………………………………… 82

XXXII.. RESULTS OF BIVARIATE BINARY LOGISTIC REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV………………………………….. 83

XXXIII. RESULTS OF BINARY MULTIPLE LOGISTIC REGRESSIONS EXAMINING THE INFLUENCE OF ALL SIGNIFICANT VARIABLES FROM ALL 3 ANALYTIC CONSTRUCTS (INTRAPERSONAL LEVEL, PERCEIVED CONTROL OVER BECOMING INFECTED, AND PROTECTIVE ACTIONS TAKEN) ON SELF-PERCEPTION OF RISK FOR HIV (NUNLIKELY=81, NLIKELY=74, UNLIKELY AS REFERENCE) ………………………… 84

XXXIV. RESULTS OF EXAMINATION ON THE MODERATION OF CONSISTENT CONDOM USE OF EXPERIENCE OF WORKING IN BAR/DISCOTHEQUE ON SELF-PERCEIVED RISK FOR HIV ……… 86

XXXV. RESULTS OF LOGISTIC BINARY REGRESSION OF SELF- PERCEIVED FOR HV INFECTION ON EXPERIENCE OF WORKING IN BAR/DISCOTHEQUE ADJUSTING FOR CONSISTENT CONDOM USE ……………………………………………………………. 87

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LIST OF TABLES TABLE PAGE

XXXVI. RESULTS OF BINARY LOGISTIC REGRESSION OF CONSISTENT CONDOM USE ON EXPERIENCE OF WORKING IN BAR/DISCOTHEQUE ………………….……………… 88

XXXVII. RESULTS OF THE EXAMINATION ON MODERATION OF CONSISTENT CONDOM USE ON THE EFFECT OF SELF- PERCEIVED RISK FOR GONORRHEA ON SELF- PERCEIVED RISK FOR HIV …………………………………………… 89

XXXVIII. RESULTS OF LOGISTIC BINARY REGRESSION OF SELF- PERCEIVED FOR HV INFECTION ON SELF-PERCEIVED RISK FOR GONORRHEA ADJUSTING FOR CONSISTENT CONDOM USE …. 90

XXXIX. RESULTS OF BINARY LOGISTIC REGRESSION OF CONSISTENT CONDOM USE ON SELF-PERCEIVED RISK FOR GONORRHEA … 91

XL. RESULTS OF THE EXAMINATION ON THE MODERATION OF CONSISTENT CONDOM USE ON THE EFFECT OF SELF- PERCEIVED RISK FOR SYPHILIS ON SELF-PERCEIVED RISK FOR HIV …………………………………………………………………… 92

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LIST OF FIGURES FIGURE PAGE

1. Map of Indonesia …………………………………………………………….. 4 2. Condom use among high risk groups…………………………………....... 15 3. The Social Ecological Model ...................................................................... 38 4. Conceptual framework of the study ........................................................... 41 5. Distribution of people living with HIV/AIDS, the brothel compounds

and health care services for HIV/AIDS in Surabaya …………………….. 44 6. Analytical framework ................................................................................... 63 7. The model of factors influencing female sex workers’ self-

perceived risk for HIV in Surabaya ….......................................................... 85 8. The final model of factors influencing female sex workers’ self

-perceived risk for HIV in Surabaya............................................................. 93

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LIST OF ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome ART Anti-retroviral Therapy ARV Anti Retroviral CST Care, Support and Treatment DHF Dengue Haemorrhagic Fever FSW Female Sex Workers HIV Human Immunodeficiency Virus IBBS Integrated Bio-Behavioral Survey IDU Injection Drug User MOH The Ministry of Health (of the Republic of Indonesia) MSM Man who have Sex with Men NGO Non-governmental Organization STI Sexually Transmitted Infection STD Sexually Transmitted Disease UNAIDS United Nations General Assembly Special Sessions on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund

UNIFEM United Nations Development Fund for Women VCT Voluntary Counseling and Testing

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SUMMARY

A study on perception of risk for HIV among brothel-based female sex workers was

carried out using an analytical, cross-sectional approach. Unlike female sex workers practicing

commercial sex in social environments where little information about HIV is available, those

working in Surabayan brothels are required by the local commitment to have regular clinical

check-ups that include counseling sessions about how to avoid STIs.

In 2012, interviews were conducted with 155 female sex workers of 6 brothel

compounds in Surabaya, Indonesia. Information on the following items were collected from the

workers: demographics, sex work history, perception on risk for certain diseases, knowledge on

HIV, self-perceived control over becoming infected by HIV, protective actions including condom

use consistency and self-perceived risk for HIV. The interviewees were asked to rate their

perception on their own risk for HIV and other diseases. They were also asked about their belief

that certain actions could prevent themselves from becoming infected by HIV. The interviewees

were also asked to report their frequency of practicing actions to prevent themselves from

acquiring HIV, including the use of antibiotics and condom use.

The results of the study indicated that female sex-workers who consistently used

condoms were less likely to perceive themselves as being at risk for HIV than those who

inconsistently used condoms while serving their clients. Those who worked in

bars/discotheques in the last 12 months were more likely to perceive themselves as being at

risk for HIV than those who did not work in those places. Self-perceived risk for HIV was higher

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among sex-workers who perceived themselves as being at risk for gonorrhea than those who

did not. Female sex workers who perceived themselves as being at risk for syphilis were more

likely to perceive being at risk for HIV than those who did not. Self-perceived control over

becoming infected by HIV among the sex workers was not related to their self-perceived risk for

HIV.

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I. INTRODUCTION

For years, the concept of perceived risk has been central for behaviorists as shown

in the Health Belief Model (Rosenstock in Glanz, et al., 2008) and Theory of Reasoned

Action (Ajzen and Fishbein in Glanz, et al., 2008). This concept has also been essential for

health interventionists in HIV prevention programming as changing the perceived risk in such

interventions is believed to result in avoidance of HIV risky behaviors (UNAIDS, 1999; the

Ministry of Health of the Republic of Indonesia, 2009a). This attention highlights the

importance of understanding the determinants of perceived risk, particularly among the

most-at-risk-groups.

Risk is perceived differently among different communities as the concept of risk is

socially constructed and can change over time (Renn, 1992). Findings by the Ministry of

Health of the Republic of Indonesia (MOH) confirm this statement. Results from its national

Integrated Bio-Behavioral Surveillance Surveys (IBBSs) in 2002, 2004 and 2007 persistently

show that the most-at-risk groups, including subgroups of FSWs, vary in perceiving their risk

for HIV, even among themselves (MOH, 2009b). Over the years, for example, findings from

these surveys indicate that the percentage of FSWs who feel themselves at risk for HIV has

increased, but their correct level of knowledge about HIV appears to have decreased (MOH,

2009a). These findings suggest that many FSWs calculate their likelihood of becoming

infected based on misconceptions and/or low knowledge about HIV infection. Meanwhile,

condom use has remained low and HIV prevalence has increased among FWS during the

same time period in which these 3 surveys were conducted. Understanding the factors that

influence FSW’s perception of HIV-risk, including possible misconceptions and lack of key

adequate information, is very much needed in the country’s fight against AIDS.

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This study explored the extent to which the following items influence the FSWs’

perceived risk for HIV infection within the context of current Indonesian local governments

and socio-political dynamic: brothel-based FSWs’ characteristics, perception on sex work

experience, migration history, knowledge on HIV, peers’ support, brothel managers;

support, NGOs’ support, STI/HIV check-up facilities, source of HIV information and stigma.

The reasons for selecting these factors are discussed in-depth in other sections. The results

of the study were expected to identify and yield a better understanding of the key factors that

influence FSWs’ perceived risk for HIV. Such scientifically derived knowledge is essential in

designing more effective prevention messages and risk-reduction programming for this

highly vulnerable population.

A. The AIDS Epidemic in Indonesia

1. Indonesia - an overview

Indonesia, consisting of 17,508 islands, is an archipelagic country in

Southeast Asia and Oceania,. It was estimated in 2012 that Indonesia is inhabited by

248,216,193 people, making it the world's fourth most populous country. It is the residence

of the world's largest population of Muslims. Its age structure in 2011 was as follows: 0-14

years (27.3%), 15-64 years (66.5%) and more than 64 years (6.1%). The median age of its

people was 28.2 years. The estimated population growth rate was 1.04%, and its birth rate

was 17.76 per 1,000 population in 2012. Urban population makes up 44% of its total

population, and the rate of urbanization is estimated as 1.7%. Its major cities are Jakarta

(9.121 million people), Surabaya (2.509 million people), Bandung (2.412 million people),

Medan (2.131 million people) and Semarang (1.296 million people) (Central Intelligence

Agency, 2012). There are 450 distinct ethnic and linguistic groups, and five major religious

groups in the country.

In 2011, Indonesia’s estimated GDP (purchasing power parity) was

US $1.121 trillion, ranking them 16th in the world. The GDP real growth rate was 6.4%, while

3

its GDP per capita was US $4,700. Its labor force was 117 million, and its distribution by

occupation was 14.9% agriculture, 46% industry, and 39.1% services (Central Intelligence

Agency, 2012). From 2009 to 2011, there seemed to be a gross shift of occupation from

agriculture to industry. In 2009, labor force in the agricultural sector was 42.1% while it

was18.6% in the industry (Central Intelligence Agency, 2010). Sex workers in Indonesia

usually mention their kind of occupation as service. From the available information, however,

it is not clear whether sex work falls in the service category. In 2011, the unemployment rate

was estimated as 6.7% and the population below the poverty line was 13.3% (Central

Intelligence Agency, 2012), both of which showed improvements from the 2009 figures. In

2011, the following characterized the country’s health profile: less than 5% of its GDP

devoted to health expenditure, a total health expenditure per capita of US $51, a nursing and

midwifery personnel of 179,959, a physician personnel of 65,722, an under-five mortality rate

of 35 per 1,000 live births, and an infant mortality rate of 27 per 1,000 live births (Global

Fund, 2011).

4

Figure1. Map of Indonesia.

Source: www.google.com

2. Epidemiology of HIV in Indonesia

The first reported case of AIDS in Indonesia was that of a foreign male tourist

in 1987 (Mboi and Smith, 2006; WHO, 2007). By 2004, the country experienced a spurt in

HIV incidence among Indonesians that peaked in 2008, but then slightly decreased in 2009.

With an HIV/AIDS prevalence rate in 2008 that was 15 times higher than the national

average, Papua was especially affected (UNAIDS, 2010). By 2009, it was estimated that the

overall number of people living with HIV/AIDS reached 333,200. In 2010, the national

prevalence was 0.1% while in its easternmost provinces of Papua and West Papua,

HIV/AIDS grew to a low epidemic level. As seen, the country itself had entered a

concentrated epidemic state (MOH, 2011). Heterosexual transmission has been known as

5

the major mode of HIV transmission in Indonesia and commercial sex work has been linked

to this spread.

Judging by epidemiological trends within the last decade, Indonesia is poised

to be one of the fastest growing AIDS epidemic countries in Asia (WHO, 2007). All the

factors needed for rapid spread are present in Indonesia, and include: a huge unreported

formal and informal sex industry; limited health facilities for sexually transmitted infection

detection and care services; a highly mobile population; a growing epidemic among injecting

drug users; the effects of a major economic crisis in 1997 driving women to work in sex

industries and children to work on the streets and the shifting yet unclear roles of different

health authorities at various levels due to decentralization in the early 2000s (USAID, 2003).

3. Geographical distribution

Geographically, the current distribution of HIV/AIDS is relatively consistent

with those in the past 10 years. Table I presents the AIDS prevalence in Indonesia by

province.

As revealed in Table I, the most prevalent HIV provinces coincide with

Indonesia’s most industrialized sites: Papua, Bali, Kepulauan Riau and Jakarta (see MOH

HIV/AIDS Annual Reports, 1996-2011). The highest numbers of cases were reported from

these provinces and East Java Province.

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TABLE I

AIDS PREVALENCE PER 100,000 POPULATION BY PROVINCE IN 2010 No. Province Prevalence

1 Papua 173.69

2 Bali 49.16

3 DKI Jakarta 44.74

4 Kepulauan Riau/Riau Archipelago 24.96

5 Kalimantan Barat/West Kalimantan 23.96

6 DI Yogyakarta/Jogjakarta 14.82

7 Maluku/Moluccas 14.21

8 Bangka Belitung 11.65

9 Jawa Timur/East Java 10.44

10 Jambi 9.37

11 Sumatera Barat/West Sumatra 9.10

12 Papua Barat/West Papua 8.93

13 Jawa Barat/West Java 8.91

14 Riau 8.39

15 Sulawesi Utara/North Sulawesi 7.69

16 Bengkulu 7.49

17 Sulawesi Selatan/South Sulawesi 6.65

18 Nusatenggara Timur/East Nusa Tenggara 5.55

19 Sumatera Utara/North Sumatra 3.88

20 Banten 3.86

21 Nusatenggara Barat/West Nusa Tenggara 3.07

22 Sumatera Selatan/South Sumatra 3.04

23 Jawa Tengah/Central Java 2.92

24 Kalimantan Tengah/Central Kalimantan 2.40

25 Lampung 1.86

26 Maluku Utara/North Moluccas 1.77

27 NAD/Aceh 1.29

28 Sulawesi Tenggara/SE Sulawesi 0.95

29 Kalimantan Selatan/South Kalimantan 0.78

30 Sulawesi Tengah/Central Sulawesi 0.46

31 Kalimantan Timur/East Kalimantan 0.35

32 Gorontalo 0.33

33 Sulawesi Barat/West Sulawesi 0.00

National 10.46

Source: MOH, 2011

The two provinces of Tanah Papua (the Land of Papua) reported the highest

prevalence in 2010 compared to that of other provinces and the national average.

Geographic barriers contribute to this high prevalence. The inner parts of Tanah Papua are

difficult to access as its topography is dominated by a mountainous area of over 5,000

7

meters in altitude, 75% of which is covered by dense forestation. Large areas of swampland

make its coastal parts (UNDP, 2005). The limited infrastructure and geographical barriers

make the vast majority of Tanah Papua accessible only by foot or airplane (Butt, 2001).

Sometimes, one has to walk for 6 hours to reach populations in the mountainous area

(Doctors Without Borders, 2010). Commercial sex transactions, however, have been

reported as occurring in the mining sites deep inside the forests (AmfAR, 2005).

4. Ethnic groups affected

Despite its ethnic diversity, there seems to be no difference on HIV

prevalence by ethnicity in Indonesia, except in Tanah Papua. Differing circumcision rates

and attitudes toward condom use and sexual behaviors may partly explain the reported

difference in HIV/AIDS prevalence between Papuans and other ethnic groups in Indonesia.

Circumcision has been demonstrated to provide a 60% protection rate against HIV

acquisition (Bailey, et al., 2007). In 2006, only about 5% of ethnic Papuan men as compared

to 70% of non-Papuan males residing in Tanah Papua were circumcised. Meanwhile, the

HIV/AIDS prevalence among men residing in Tanah Papua who had not been circumcised

was 5.6% as compared to 1.0% among their circumcised counterparts (National AIDS

Commission, 2008), thereby strongly suggesting that circumcision is a protective factor

against HIV. The national average of circumcision rate for Indonesia was as high as 88.2%

(Waskett, 2011).

5. Age distribution

For the most part, people 15-49 years of age are the most likely to become

HIV infected as shown below in Table II.

8

TABLE II

NEW AIDS CASE DISTRIBUTION BY AGE IN INDONESIA, 2005-2011

No Year Age group (years) Unknown Total

< 1 1-4 5-14 15-19 20-29 30-39 40-49 50-59 > 60

1. 2005 12 10 7 74 1,459 690 216 60 0 111 2,639

2. 2006 8 46 10 29 1,610 850 196 60 5 59 2,873

3. 2007 14 41 17 56 1,535 889 247 56 11 81 2,947

4. 2008 65 56 45 216 2,165 1615 475 152 40 141 4,969

5. 2009 68 62 32 115 1,614 1290 392 115 13 163 3,863

6. 2010 54 76 46 150 1,907 1681 633 204 33 133 4917

7. 2011* 12 36 15 53 558 599 251 121 31 129 1,805

* = through September 2011 Source: Ministry of Health of the Republic of Indonesia, 2011

Within age groups, new AIDS cases in Indonesia have primarily occurred among people who

were between 20-29 years old. Risky heterosexual behaviors and needle sharing among

injection drug users in this age group made the major modes of HIV transmission

comparable. Both transmission routes have alternately led the mode of HIV spread since

2005. In Tanah Papua, the HIV prevalence in this age group was as high as 2.4%. This was

driven almost solely by risky sexual behaviors among the youth in the general population

(National AIDS Commission, 2009) as well as in industrialized sites that rapidly grew with the

accompanying fast-growing sex industry (Papua Commission on AIDS Prevention, 2011).

6. Gender distribution

Males dominate Indonesia’s newly diagnosed AIDS cases, although the rates

for women are steadily increasing. In 2005, 19.5% of the people infected with the virus were

women, while by 2011, women accounted for 34% of people living with HIV. This trend

suggests the feminization of the HIV epidemic in Indonesia and that mother-to-child

transmission is becoming worrisome. Table III presents the AIDS case distribution by sex in

Indonesia from 2005 to 2011.

9

TABLE III

NEW AIDS CASE DISTRIBUTION BY SEX IN INDONESIA, 2005-2011

No Year Sex Total

Male Female Unknown

Number % Number % Number %

1. 2005 2,112 80.0 514 19.5 13 0.49 2,639

2. 2006 2,299 80.0 572 19.9 2 0.07 2,873

3. 2007 2,260 76.7 686 23.3 1 0.03 2,947

4. 2008 3,197 64.3 1755 35.3 17 0.34 4,969

5. 2009 2,659 68.8 1193 30.9 11 0.28 3,863

6. 2010 3,238 65.9 1662 33.8 17 0.3 4,917

7 2011 1,118 61.9 613 34.0 74 4.1 805

T* = through September 2011

Source: MOH, 2011

7. Distribution of risk factors associated with vulnerability to HIV

For more than two decades, heterosexual transmission and needle sharing

among drug users were the two most common modes of infection in Indonesia (MOH, 2010).

The following table depicts change in modes of AIDS transmission in the last ten years.

TABLE IV AIDS CASE DISTRIBUTION BY RISK FACTORS IN INDONESIA, 2001-2005

AND 2006-2011 No Risk factor 2001-2005 2006-2011

Number of case proportion Number of case proportion

1. IDU 2,501 53% 6,381 34%

2. Heterosexual 1,718 37% 10,337 55%

3. MSM 159 6% 760 4%

4. Mother to child and contamination with blood or blood product

59 1% 615 3%

5. Unknown (unanswered) 257 3% 483 4%

2011: through September 2011

Source: MOH, 2011

AIDS data on sex workers are limited on HIV positive cases and prevalence.

From 2002 to 2005, HIV cases among direct sex workers increased from 4.9% to 8.1%,

10

while from 2006 to 2007 the figure increased from 8.8% to 9.4%. The numbers of HIV cases

in 2007 were 2,071 among brothel-based FSWs, 249 among street-based FSWs, 671

among karaoke/bar FSWs and 1,365 among massage parlor FSWs (Magnani, et al., 2010).

8. Stigma, gender inequities and opposition groups

Stigmatized people face many issues in their communities that cause

discouragement in seeking information on their HIV status. In some cases, the issues are

often related to public health facilities. High-risk populations that include FSWs and

transgender people are marginalized despite legal guarantees of their rights to access public

health services (Pisani, 2008). Consequently, female sex workers who are usually

stigmatized incline to self-treat or seek more expensive services from private healthcare

providers rather than access public health services (Mboi & Smith, 2006).

In most parts of Indonesia, gender inequities complicate HIV/AIDS detection

and prevention efforts. Sexual health behaviour in relation to HIV/AIDS is predominantly

determined by men. Particularly in sexual relations, males decide under what circumstances

they wish to have sex and whether or not a condom is used (Mboi & Smith, 2006).

Opposition groups have also shaped the delays in taking the decisive action

in HIV/AIDS prevention. In many areas, conservative groups (mostly faith-based) perceive

condom promotion as an encouragement of immoral behaviour, and therefore resist condom

promotion and any policy related to sex work. These groups tend to choose repression or

elimination of sex work, thereby making it challenging to access sex workers and their clients

in order to provide HIV/AIDS education, condoms, and more general health services (Pisani,

2008). In a few areas such as the District of Banyuwangi, the adoption of comprehensive

local regulations, including a requirement of 100% condom use in high-risk sex, is effective

(Mboi & Smith, 2006).

11

9. Government’s policy response

For many decades, Indonesian FSWs, particularly brothel-based ones, have

been subject to social and political dynamics. In the past two decades in the milieu of

brothel-closing policy controversies in the communities, their workplaces have either already

been closed or are subject to future closure by the local governments. Many believe that

closing one ‘lokalisasi’ – the popular name for a brothel compound - will generate new,

uncontrolled brothels in other parts of the country as the demand for sex service is steady.

Sexually transmitted diseases and HIV are believed to grow uncontrollably under this

situation. Because workplace closures forced FSWs to quit sex work, the FSW population

has declined over the last decade as indicate by data (Basuki, et al., 2002; Rismaharini,

2012). In the remaining brothel compounds, potential brothel closure poses mental and

economic insecurity among the FSWs and likely adds to the stigma (Mboi & Smith, 2006)

and shame that have been attached to them for centuries. Brothel managers are also

affected by these local policies. Outreach workers organized by nongovernmental

organizations (NGOs) working with brothel-based FSWs will likely be affected by these

policies as well. A further examination is needed on whether these local social-political

situations affect FSWs’ selection on HIV information and its source. Given that FSWs’

correct perception of HIV risk is the ultimate goal of sensitization in HIV programming and

the intermediate aim for HIV prevention, it is of utmost importance that further exploration

takes place in perception building under these socio-political circumstances.

10. Public health response

Indonesia joined the World Health Organization’s global campaign to provide

ARV treatment to patients. The campaign requires a major expansion of services for both

HIV Voluntary Counselling and Testing (VCT) and Care, Support and Treatment (CST). VCT

has been introduced to accommodate the needs of prevention, diagnosis, counselling and

antiretroviral therapy (ART) since 2004 (the National AIDS Commission of the Republic of

12

Indonesia, 2010). The government also provides testing centers with the reagents needed

for HIV testing. In 2011, there were 388 operating VCTs, which were mainly government

owned (MOH, 2011). The majority of VCT clients are people from high-risk groups and their

partners. In IBBS 2007, 24% of IDUs, 18% of MSM, 17% of waria, 9% of indirect FSWs and

4% of FSWs’ clients were reported to have been tested. Overall, 292 CST services, 643 STI

clinics and 81 mother-to-child transmission prevention services were available for those who

might be at risk or who had contracted the virus. The numbers of AIDS cases treated with

ARV through September 2011 were 22.843, 96% of whom were adults and 4% of whom

were children. Ninety-five percent first line and 5% second-line regiments were administered.

B. Sex Work and HIV among Female Sex Workers in Indonesia

1. Commercial sex work in Indonesia

Prostitution in Indonesia has dual faces. On the one hand, it is legally

considered a crime. On the other hand, it is widely practiced, tolerated and regulated (see

Sedyaningsih -Mamahit, 2002; Gorman, 2011). Little has been reported on non-female sex-

workers.

As in other societies, some women in Indonesia enter sex work voluntarily for

financial reasons, while others are forced or trapped by friends, relatives, or strangers to be

FSWs (Magnani et al, 2010; Sedyaningsih-Mamahit, 2002). Two types of FSWs are

presentin Indonesia: direct and indirect. Direct FSWs earn money mainly from their sex work

either in brothel compounds or on the street. Indirect FSWs have main jobs in discotheques,

karaoke-bars, hotels, motels or massage parlors and earn additional income from sex work

(MOH, 2009; Sedyaningsih-Mamahit, 2002). In 2007, the estimated numbers of direct FSWs

was 95,000 - 157,000 and indirect FSWs was 85,000- 107,000 (MOH, 2009b). Online

prostitution is also common. On internet forums, FSWs are offered to registered members.

"Free reports" containing descriptions of the members’ experience with FSWs are shown on

the web. Private messaging is used when contact information is requested. Nowadays,

13

social media also facilitates linking FSWs to prospective clients. Also, prostitution rings on

social media have been reported.

In Indonesia, one of the main reasons for a woman to enter sex work is the

attractiveness of earning money quickly. In Java, many low-priced FSWs start their sex work

as part-timers in food stalls (Koentjoro, 2004). At the lower end, street-based FSWs in

Surabaya might earn only Rp. 25,000 (US$2.50) per client (Gorman, 2011). On average,

direct FSWs in Surabaya charged Rp. 89,000, with the median of Rp. 70,000 per client

(MOH, 2009a). High-end FSWs in Jakarta could earn US$ 2,500 per month (Kendall, et al.,

2010). Nationally the average and median figures were Rp. 118,000 and Rp. 80,000,

respectively (MOH, 2009a).

It was estimated that the annual sex sector’s financial turnover was between

0.8% and 2.4% of Indonesia’s GDP (US$1.2 – 3.3 billion). In Jakarta alone, the annual

turnover of activities related to transactional sex was estimated at US$ 91 million. Money

earned was sent by the sex workers from their workplaces in urban brothel compounds to

their families residing in the villages. (Kendall, et al., 2010)

Besides economic reasons, prostitution in Indonesia might also relate to life

style choices and ritual beliefs (Koentjoro, 2004).

2. HIV among female sex workers in Indonesia

Several surveys on direct FSWs’ HIV sero-statuses have been conducted in

four to eight cities in Indonesia between 2002 and 2007. While FSWs of Sorong in Papua

constantly hold the highest HIV prevalence over the periods, the steepest increase of HIV

prevalence among direct FSW subpopulation was found in Surabaya - from 3.8% to 10.2%

(Magnani et al., 2010).

14

3. The suspected role of FSWs on bridging the epidemic to the general

population

In 2007, depending on the workplace, HIV prevalence among sex workers in

2007 was between 4.2% - 10.8%. This statistic is lower than HIV prevalence among injecting

drug users (IDUs) for whom prevalence was estimated at 43%-56%, depending on which

city is being considered (MOH, 2009b). However, because sex workers are suspected of

forming the “bridge population” through which HIV crosses over from drug users to

commercial sex clients in the general population, the Indonesian National AIDS Commission

(NAC) predicts that men infected by HIV through paid sex with women will become the

largest contributors to new HIV infections in Indonesia in the period from 2007 to 2020

(Magnani, et al., 2010).

Results from the Indonesian Integrated Biological Behavioral Surveillance in

2007 (IBBS 2007) showed that more than 30% of IDUs bought sex, of which only 32% wore

condoms while doing so. Fifty seven percent of FSWSs’ clients were reported as never

wearing condoms when they bought sex, and 71% never wore condoms when they were

having sex with their wives (MOH, 2009). The AIDS commission’s prediction was also based

on the fact that the sex industry in Indonesia was fast growing. Figure 2 presents a diagram

of condom use among IDUs, FSWs and FSWs’ clients, which is summarized and drawn

based on available information reported in 2009 by the Indonesian Ministry of Health (MOH).

15

43% 32%%

? N/A

N/A

N/A

N/A

N/A

Figure 2. Condom use among high risk groups. Summarized from MOH’s report (2009) Note: N/A = data not available

With low-condom use in sexual encounters as depicted in Figure 2, HIV

transmission to the general population can be expected. In fact, as many as 288 new cases

of AIDS among low-risk housewives were reported in 2011. This is the highest number of

new cases among other groups (MOH, 2011). Therefore, FSWs are seen as key in HIV

transmission to the general population. Their self-perception of risk for HIV is important in

HIV prevention (MOH, 2009a).

C. Perception of Risk for HIV

1. The concept of perceived risk

Risk refers to “the likelihood of an unwelcome outcome being realized” and is

formulated quantitatively as “probability times severity of harm” (Bennet, et al., 2010). The

latter concept implies the importance of understanding basic probability concept, which in

many cases of public health cannot be achieved.

The characteristics of risk include: “generally less acceptable if perceived to

be involuntary; asymmetrically distributed; preventable by taking personal precautions; rising

29%

FSWs

Injecting drug users

Low risk men FSWs’

clients

(68% were

married)

Male sex

workers

Regular partners

FSWs’ clients (30% of

IDUs)

16

from an unknown or new source; resulting from artificial instead of natural resources;

causing unseen and permanent harm; generating some specific danger to little children,

expectant women, or more generally to coming generations; threatening a form of death;

damaging identifiable rather than anonymous victims; incomprehensible by science; and the

subject of contradictory statements from responsible sources.” (Bennet, et al., 2010).

Perceived risk or susceptibility refers to ‘beliefs about the likelihood of getting

a disease’ (Rosenstock, 1990). Self-perceived risk for HIV refers to one’s opinion of his/her

chances of getting HIV, while perceived risk of others for HIV is defined as one’s opinion of

his/her peers’ chances of getting HIV (Linville, et al., 1993).

2. Assessment of self-perceived risk for HIV

Perceived risk can be either self-perceived risk for HIV or perceived risk of

others for HIV. Self-perceived risk can be assessed quantitatively and qualitatively.

Quantitative measurement relies on the perceived probability of getting HIV expressed in

percentages. This method is proven reliable when applied to knowledgeable people who

understand the basic concept of probability or odds (Linville, et al., 1993), suggesting that

people are relatively constant in their beliefs about risk.

3. Biases of self-perceived risk assessment

Apart from its measurement issues, perceived risk assessment is also subject

to biases. Self-assessment results on the probability of HIV events can be misleading. On

the one hand, this self-assessment is subject to probability overestimation, which can result

from availability, confirmation and overconfidence biases. Availability bias occurs when one

overestimates his/her own risk for HIV because the events related to HIV/AIDS are

personally more memorable to him/her and are hence, more available (Van der Pligt, et al.,

1993; Bennet, et al., 2010). Confirmation bias occurs when one has already had his/her own

17

view of HIV and any information that conforms to the view will be regarded as proof-positive.

In addition, any ambiguous data is viewed as confirmation of the view, thereby leading to an

overestimation on his/her risk. Overconfidence bias occurs as people tend to believe that

their own scientific prediction of a probability of HIV event is accurate.

On the other hand, risk underestimation is not infrequent. Knowledge about

HIV transmission is fundamental for self-appraisal of risk for HIV. However, knowledge on

the serostatus and sexual behavior of a sexual partner are frequently unavailable for many

reasons. Hence, assessments on self-perceived risk might frequently be based on sexual

partner’s physical appearance (Van der Pligt, et al., 1993), leading to an underestimation

when the infection has not yet reached the AIDS stage. Even people, who are more likely to

be well-informed about HIV, the gay population for instance, underestimate their risky

behavior (Bauman and Siegel, 1987). In addition, it is difficult to conceptualize ‘small

probability of risk’ (Bennet, et al., 2010). This will likely occur when measuring perceived risk

in places like Indonesia because the prevalence is small in the general population. However,

within FSW communities, the probability of acquiring HIV is greater, and hence,

underestimation will likely occur.

Risk underestimation can also occur as the result of unrealistic optimism,

which is a sense that one is less at risk for HIV than others from the same group. When the

risky event is considered as manageable and can be prevented through caution or effort,

optimism bias is often augmented. It could result from egocentric bias, which is the feeling

that one has more knowledge of their own protective actions than those of others (Van der

Pligt, et al., 1993). In this situation, people feel that they are unlikely to be susceptible to

negative events.

18

4. Self-perceived risk for HIV in the general population

Prohaska, Albrecht, Levy, and Kim (1990) examined heuristic factors

influencing self-perceptions of risk for AIDS among the US population in Chicago and its

surrounding sub-urban areas. The study results showed that the following influence self-

perception: demographic characteristics, sexual practices, moral assessments of people

living with AIDS, emotional reactions to AIDS and protective actions in response to AIDS.

The escalated perceptions of risk are significantly related to the number of sexual partners

over the past 5 years. Knowledge of sexual partners' past sexual behavior is also associated

with the increased perceptions of risk. Significant contributors of self-perceived risk also

include fear of AIDS, shame associated with having AIDS and concern about one's health.

Greater perceptions of risk are also reported among Asian-Americans and persons without

particular religious affiliation. The authors recommend further attention to heuristic factors in

considering theories of risk.

A study conducted by Linville, Fischoff and Fischer (1993) shows, as many

expect nowadays, that sexual activity correlates to self-perceived risk for HIV. More

specifically, it reveals that among college students, self-perception of risk level for HIV

acquisition correlates with their experience of (1) having had unprotected sex with someone

at risk for HIV infection during the last 10 years, (2) the number of episodes of intercourse

without a condom during the last 3 months, (3) the number of episodes of sexual

intercourse during the last 3 months, (4) the number of expected episodes of intercourse

with each partner in the next 3 years and (5) percentage of partners in the next 3 years

expected to be HIV infected.

In 2004, Ward, Disch, Levy and Schensul conducted a study on risk

perception for HIV among urban, low-income senior-housing residents. It revealed that the

following groups were more likely to perceive themselves at risk for HIV/AIDS: males,

19

participants aged 50–61, those who worried more about contracting HIV/AIDS and tenants of

higher risk buildings.

5. Self-perceived risk for HIV among FSWs

As revealed in the Indonesian IBBSs of 2002, 2004 and 2007, the proportions

of direct FSWs who perceived themselves to be at risk for HIV increased over time: 46%,

53% and 66%, respectively (MOH, 2009b). Factors that have been found to be directly and

indirectly associated with self-perceived risk among FSWs internationally are discussed

below.

a. Demographic characteristics

FSWs’ age and level of education have been associated with HIV

acquisition among FSWs in Indonesia (Magnani et al., 2010). Whether the level of correct

perception is the intermediate factor between these characteristics and HIV acquisition has

not been explored. Among mobile FSWs in India, age was significantly associated with

perception of HIV acquisition (Jain, et al., 2011).

Being migrant has been suspected as a risk factor for HIV infection.

Misperceptions on the risk for HIV among Myanmar migrant sex workers in Thailand have

been noted by the International Organization for Migration (2007). Lack of access to HIV-

related health facilities and language barriers might contribute to this misperception.

Magnani et al. (2011) reveals that being a resident of Bali has been associated with HIV

infection. Wirawan, Fajan & Ford (1993) found that only 34% of FSWs in Denpasar and Kuta

(Bali, Indonesia) perceived themselves to be at risk. Most FSWs (89%) studied came from

rural and urban East Java, raising suspicion of a possible association between being a

migrant and lower risk perception. Another study revealed that as many as 45% of FSWs in

Kepulauan Riau (Riau Archipelago) came from East Java. Although the least mobile

population when compared to transgender (31%) and male sex workers (35%), the

20

proportion of female sex workers (16%-19%) involved in within-country-migration cannot be

ignored (Sub-directorate of HIV and STI, MOH, the Republic of Indonesia, 2005).

b. HIV knowledge

Knowledge is defined as ‘objectively verifiable truth’ (Simons-Morton,

et al., 2012). Sensitization of risk for HIV through correct knowledge building is an essential

element of HIV prevention programming (UNAIDS, 1999). Therefore, for monitoring

purposes, the United Nations General Assembly Special Session on HIV/AIDS (UNGASS)

issued guidelines on the construction of core indicators of level of knowledge (UNGASS,

2010). For most-at-risk-groups, comprehensive knowledge on HIV includes correct

knowledge about false beliefs of possible modes of HIV transmission. To assess these

groups’ knowledge, these five questions are to be asked in a regular monitoring process:

“1. Can having sex with only one faithful, uninfected partner reduce the risk of HIV

transmission?

2. Can using condoms reduce the risk of HIV transmission?

3. Can a healthy-looking person have HIV?

4. Can a person get HIV from mosquito bites?

5. Can a person get HIV by sharing a meal with someone who is infected?”

(UNGASS, 2010)

Correct knowledge, correct conception and correct perception on HIV and its prevention are

expected to lead people to correct HIV prevention (MOH, 2009). For years, intervention

programming is aimed at delivering the correct knowledge to FSWs. However, IBBS data

show that correct knowledge on HIV among direct FSWs is not always increasing. Table V,

adopted from the Ministry of Health’s report in 2009, presents the level of knowledge on HIV

transmission among Indonesian direct FSWs. Table VI below presents the percentages of

IBBS respondents who have correct knowledge on HIV prevention during the years 2002,

2004 and 2007.

21

An intervention study in the Philippines (Morisky, et al., 2008) revealed that

perceived risk was negatively associated with knowledge, suggesting that factors other than

knowledge may contribute to self-perception shaping.

TABLE V

KNOWLEDGE ON HIV TRANSMISSION AMONG DIRECT FSWS IN INDONESIA

IN 2002, 2004 AND 2007

Knowledge on HIV transmission Year of IBBS

2002 2005 2007

Percentage of respondents who knows that HIV is not transmitted through mosquito bites 77 73 52

Percentage of respondents who know that HIV is not transmitted through sharing dining

equipments with people living with HIV/AIDS

78 72 56

Percentage of respondents who know that HIV can be transmitted through needle sharing 46 55 86

Source: MOH, 2009a

TABLE VI

CORRECT KNOWLEDGE ON HIV PREVENTION AMONG DIRECT FSWS IN INDONESIA

IN 2002, 2004 AND 2007

Knowledge on HIV prevention Year of IBBS

2002 2005 2007

Knowing that HIV infection can be prevented using condom during

intercourse

65% 73% 79%

Knowing that HIV infection can be prevented by being faithful to one-another

with the same partner

78% 72% 56%

Knowing that antibiotics cannot prevent HIV infection 59% 59% 46%

Percentage of respondents who know that HIV cannot be prevented by

consuming healthy food

74% 65% 45%

Source: MOH, 2009a

22

c. Sex work experience

Earlier age of commercial sex debut is correlated with higher HIV

prevalence (MOH, 2009). However, whether it impacts self-perceived risk for HIV has not

been explored. In many studies, almost all FSWs misperceived that sexual intercourse with

regular sex partners posed low risk compared with intercourse with clients (Wolffers et al.,

1999; Sedyaningsih-Mamahit, 2002; Basuki, et al., 2002; Bruce, et al., 2011) as they

perceived that these partners were not at-risk for HIV. In the Philippines (Morisky, et al.,

2008), having used condoms during the last sexual encounter among establishment-based

FSWs was associated with perceived risk for HIV.

d. Drug use and alcohol drinking

Drug use has been associated with sex work. In the US, for example,

some women working in the commercial sex sector sold sex for drugs (Ziergler and Krieger,

1997). Among FSWs in Indonesia, it was found that 1.5% of direct sex workers injected

drugs in the past and 0.7% injected drugs in the past one year (MOH, 2009a). Approximately

19% - 32% of direct FSWs, depending on the city sampled, used amphetamine (MOH,

2009b). Magnani et al. (2010) conclude that consumption of alcohol before having sex

among Indonesian FSWs was associated with a higher likelihood of gonorrhea and/or

chlamydia infection. However, whether this particular risky behavior relates to HIV risk

perception needs to be explored. Among mobile sex workers in Southern India (Jain et al.,

2011), an increase of alcohol use prior to sex was linked to a 2.36 time increase in having

current perception of high risk for HIV.

e. Perceived knowledge

Perceived knowledge results from information selection, which is done

based on one’s own perception on his/her cultural and social circumstances (Krimsky, 1992;

Renn, 1992; Rayner, 1992) and may deviate from the knowledge that is expected by health

23

education programmers. Trust is a central element of this selection process (Slovic, 1992;

Bennet, et al., 2010).

The Indonesian MOH found that misconception rates among direct

FSWs increased from 55%, 62% to 70% in 2002, 2004 and 2007, respectively (MOH, 2009).

The findings suggest that FSWs process the information differently from what is expected

and have their own perceived correct knowledge. Other sources of information which are

more trusted than formal institutions may contribute to the perceived knowledge. Other MOH

data reveals that the increasing misperception rates coincide with the increasing rate of HIV

prevalence but contradict the increasing self-perception on risk for HIV. This suggests that

factors other than perceived knowledge may contribute to self-perception. Table VII

summarizes the misconception and self-perception on risk for HIV as well as their

contribution to HIV prevalence among Indonesian direct FSWs in 2002, 2004 and 2007.

TABLE VII

MISCONCEPTION ON HIV TRANSMISSION AND PREVENTION, AND SELF-

PERCEPTION ON RISK FOR HIV INFECTION AMONG DIRECT FSWS IN INDONESIA

2002, 2004 AND 2007

Year of IBBS

2002 2004 2007

Misconception on HIV transmission and prevention 55% 62% 70%

Self-perception on at-risk for HIV 46% 53% 66%

HIV prevalence 4.9% 7.1% 9.4%

Summarized from MOH report (2009a)

f. Perceived control

The American Psychological Association (2002) defines perceived

control as “the belief that one has the ability to make a difference in the course or the

consequences of some event or experience.” In line with that definition, perceived HIV

24

control can be defined as an individual’s belief that HIV infection can be personally

controlled. Perceived control or subjective control refers to the actor’s estimation of the

control available to him or her (Skinner & Zimmer-Gembeck, 2011). It describes an important

personal resource individuals draw upon in forming appraisals and planning actions (Dweck,

1999; Folkman, 1984). This study focused on subjective control among FSWs. Objective

control conditions refer to the actual controllability of outcomes, which is the comparison of

the actual competencies of the actor versus the conditional likelihood of an outcome given

action versus the likelihood of an outcome given no action (Seligman, 1977).

g. Protective actions against HIV infection

Protective actions against HIV in this study can be classified as the

experience of control, which is one of the three kinds of controls. It is defined by Skinner

(1996) as ‘the experience of exerting effort that produces a desired outcome’ in which

desired outcomes are produced and undesired ones are prevented or terminated.

Experiences of control are distinct from objective and subjective control. During assessment,

individuals judging that particular risks are under their control tend to assess their risk lower

(Van der Pligt, et al., 1993).

Many FSWs in Asia exert control over HIV infection in many forms.

For example, they take over-the-counter antibiotics and traditional herbs and wash their

clients’ and their own genitals (Basuki, et al., 2002; Sedyaningsih-Mamahit, 2002; Yang, et

al., 2005). Antibiotics were available over the counter in many pharmacies and sold in the

streets of Surabaya, Indonesia (Hadi, et al., 2010), enabling local FSWs to consume them

unsupervised.

The use of susuk kesehatan, an implant traditionally inserted into the

human body by dukun (a shaman) aiming at preserving health, has also been known

(Greetz, 1960) and is still practiced by Javanese communities. Susuk kesehatan has not

25

been explored in the Indonesian national survey as well as in other previous Indonesian

studies (Wirawan, et al., 1993; Basuki, et al., 2002; Sedyaningsih-Mamahit, 2002; Magnani,

et al, 2010; Ministry of Health, 2009a). The use of susuk kesehatan is worth exploring and

was provided in this study as one of the questionnaire answer options. The use of shaman

service for curative purposes is also popular in rural Java (Geertz, 1960; Saleh, 2001).

Nowadays, the service has been expanded to cure HIV/AIDS (Woodward, 2011). Traditional

rites and the use of shamans in Ghana have also been mentioned by Vaughan-Smith (2007)

to cure or prevent AIDS. While other studies have not explored the use of shaman for HIV

prevention in Indonesia, this study intended to do so by listing it as one of the questionnaire

answer options.

h. Peer’s support

As well as in other Asian countries, in Indonesia, collectivism has

been embedded in its culture. Peers are significant in this culture, including in sex work.

Peers are becoming more limited in the Indonesian brothel-based FSWs’ environment,

which is in part due to brothel closure. Losing peers and their support may contribute to the

shaping of perception on risk for HIV among Indonesian FSWs. Among FSWs in China, for

example, there have also been perceptions that peers’ involvement in risky sexual behavior

such as having multiple sexual partners, purchasing commercial sex, having paid sex and

having a history of STD infection were associated with risk for HIV (Yang, Li, Stanton, Chen,

Liu and Mao (2005). However, this study did not relate this perception of other’s risk to self-

perception of risk for HIV although the authors imply so. In the Philippines (Morisky, et al.,

2008), however, peer intervention programs were less likely to cause FSWs reporting higher

perceived risk in comparison to brothel manager intervention programs.

i. Brothel manager’s support for HIV prevention

Brothel-based FSWs usually work under the control of brothel

gatekeepers, who are defined as ‘persons who manage sex workers. These include

26

mommies, pimps, establishment owners, managers, and other employees’ (Pirkle, et al.,

2007). They have frequent financial arrangements with FSWs by providing accommodations

in exchange for the services and income earned by the FSWs. Gatekeepers can also dictate

the amount charged by a sex worker, determine whether a sex worker should serve a

particular client, dictate whether the sex worker can or cannot work, hold a debt, manipulate

FSWs’ emotionally, threaten them with actual sexual and physical violence and physical

isolation, hand them over to legal authorities and force drug and alcohol use (UNAIDS,

UNFPA & UNIFEM, 2005). Although not in all aspects, some similar situations have been

found within FSWs’ worksites in Indonesia (Basuki et al., 2002). Gatekeepers’ opinions

concerning condom use and STIs are important and affect FSWs’ decisions of condom use.

Particularly in condom use, gatekeepers fear that forcing clients to use condoms will

negatively affect business and that STI education will cause girls to quit sex work and hence,

both are not encouraged (Basuki et al., 2002; Pirkle, et al., 2007). This may explain why only

about 10% of gatekeepers in China provided condoms, of whom only 8% required condom

use (Pirkle, et al., 2007). Also, FSWs who worked in brothels in South Viet Nam were less

likely to use condoms than in other places (Thuy, et al., 1998).

Brothel managers might also apply different policies for drug and

alcohol use in brothels. At one end of the continuum, Laissez-faire typed managers do not

pay attention to their employees’ health. Family-style managers ensure that their FSWs

have adequate health care and at the same time allow their FSWs to drink alcohol as long

as they do not get drunk (Sedyaningsih-Mamahit, 2002). Such working environments might

contribute to brothel-based FSWs’ self-perceived risk for HIV.

A study in the Philippines compared the difference of risk perception

among two intervention groups (Moritsky et al., 2008). In one group, the managers of the

brothel-based FSWs were trained to provide positive reinforcement of their employee’s

27

healthy sex practices. In another group, the FSWs’ peers were provided basic information on

STI and HIV, transmission modes, role playing and modeling, sexual negotiation, inside the

work establishment’s interpersonal relationships with peers and clients and normative

expectancies. At the end of the study, FSWs were asked about their self-perceived risk. The

FSWs within the manager-only intervention group were more likely to report higher

perceived risk than those with peer only. However, FSWs in the control group reported

themselves as being at higher risk for HIV. This finding suggests that factors other than the

intervention affected the perception more significantly.

In Indonesia, most brothel managers are not trained to deliver

HIV/AIDS prevention messages. In some places such as Surabaya where this study will be

conducted, however, local commitments obligate brothel managers to send their workers for

HIV counselling and testing. This proposed study will explore the extent to which brothel

managers, who lack direct intervention but are yet bound by local commitments, support

increasing awareness among their female employees of the risks involved in sex work and

ways to reduce them.

j. NGO’s support

Nongovernmental organizations (NGOs) have been involved in HIV

prevention intervention among FSW communities, particularly brothel-based FSWs in

Indonesia. On the field, they provide peer education and a wide variety of support. However,

whether the supporting roles of NGOs in Indonesia improve FSWs’ awareness of risk for HIV

is unclear. In the Philippines (Morisky, et al., 2008), members of the control group predicted

greater perceived risk, less knowledge and lower condom attitudes at the last sexual

encounter. In the study, condom attitudes were defined as positive ideas about condom

use. The study findings suggest that interventions might succeed to translate knowledge into

positive condom attitudes. The higher condom use and the lower STI incidences among the

28

intervention groups were significantly higher compared to those of the control group. In

combination with the lower perceived risk for HIV among the intervention groups, the

findings suggest that the intervention might succeed in sensitizing the FSWs to realize that

they were at risk for HIV if they did not use condoms and at lower risk for HIV if they used

condoms. The suggestion, however, has not been investigated in the study. Condom use is

one of the indicators that this proposed study will explore.

k. Experience with STI/HIV counselling and testing facilities

Health service institutions in the Russian Federation and India

frequently disapproved and refused to treat FSWs’ health problems, imposed mandatory HIV

testing, exposed their HIV status and threatened to report them to the authorities (UNAIDS,

UNFPA & UNIFEM, 2005; Zierler & Krieger, 1997). China’s public health system deliberately

excluded them from any existing prevention intervention services (Hong, Poon & Zhang,

2011). Its programs often neglected the massive problem of undocumented migrants, of

whom a considerable number were FSWs and their clients (UNAIDS, UNFPA & UNIFEM,

2005).

In public health facilities, VCT is a part of the primary health care

center’s activities at the subdistrict level (Puskesmas) prioritizing the STI or harm reduction

program. The first STI clinic in Indonesia was established long before VCT was integrated

into the clinics. In Surabaya, the STI clinics integrated into the public health clinics

incorporate STI control programs, which address gonorrhea, syphilis and chlamydia

infections. They are located adjacent to brothel compounds and the sea-port of Tanjung

Perak. Monthly physical examinations, laboratory testings and periodic presumptive

treatments for sex workers contracting STI are the main activities of the STI clinics inside the

primary health care centers. HIV VCT is encouraged every three months.

29

In Semarang, Indonesia, perception on VCT service in the preceding

visit among brothel-based FSWs was significantly correlated with attendance in the

succeeding visit three months later. Lower perception predicted lower attendance. The

perception was assessed using two indicators: counseling services and organization of the

services. Perception on counseling services was assessed using the following indicators:

waiting time, communication process, counselor’s language, counselor attitude toward client,

non-counselor attitude towards client, the usefulness of pre- and post-testing material

counseling, the quality of counselor’s pre- and post HIV test counseling, and the quality of

laboratory service. FSWs’ perceptions on the following were assessed: organization of VCT

environment, assurance of confidentiality, the availability of information on counseling

procedures, trustworthiness, comprehensiveness of services, and availability of STD/HIV

education media in the waiting room and in the counseling room.

In Semarang, HIV counseling and testing for brothel-based FSWs are

scheduled three monthly (Widianto, 2008). A government-owned STD clinic located adjacent

to brothel compounds of Dolly and Jarak in Surabaya has similar commitment with brothel

owners (private communication with Surabaya Health Office staffer, 2011). In some places

in Indonesia, mobile VCTs have reached brothel-based FSWs, enabling FSWs to access the

service more conveniently. In VCT sites, counseling is conducted by professional, certified

counselors, before and after HIV testing. In the pre-HIV-test counseling process, information

HIV and AIDS are delivered. Information on HIV testing procedure is provided and the test is

offered. Pre-test counseling can be delivered on one-on-one as well as group bases,

depending of the number of prospective FSWs visiting the VCT. Post-HIV-test counseling is

delivered on individual basis. Counselors advise HIV-negative FSWs to re-visit VCT in the

following three months and reduce their risky behavior. HIV positive FSWs are counseled for

prevention, treatment adherence and sustainable counseling (Family Health International,

30

2004). Lay counselors without health professional background have also been trained and

deployed in other resource limited countries (UNAIDS, 2000).

Overall, however, the IBBS 2007 shows that only 32% of direct FSWs

in Indonesia use VCT counselor services to gain information on HIV (MOH, 2009a). The

limited number of VCT sites nationally may explain this low use, while the price for

consultation may not, as the service is almost free for FSWs. Experience with these facilities

might also contribute to FSWs’ regular visit for information and testing as well as the

formation on self-perception of risk for HIV. Further exploration on the low use of counselor’s

service in gaining HIV information and the experience with HIV/VCT use among FSWs is

needed.

l. Sources of HIV information

Perception is the result of information interpretation from various

sources. Information can come from many sources, including experience, observations of life

events, and incidental and purposive messages (Simmons-Morton, et al., 2012). In many

instances, messages are initially judged not by its content but by its source.

Untrustworthiness to the source makes messages hard to accept. As mass media, television

can amplify the risk particularly when it questions blame and showing strong visual impact

(Bennet, et al., 2010). Message framing in health campaigns can also affect perceived risk

(Linville, et al., 1993; Calman, et al., 2010). Messages of a reduced risk for HIV when

condoms are used might lead people to conclude they are not at risk at all for HIV when they

wear condom, regardless the fact that condoms might break during its use (Linville, et al,

1993).

In the earliest days of the HIV/AIDS epidemic in Indonesia, in general,

the media was slow to take up the issue. A good article was rare. On the contrary, media

tended to publish sensational and inaccurate news focusing on death, sex, or both. This

contributed to public misinformation and a climate that stimulated fear, stigma, and

31

discrimination (Mboi & Smith, 2006). This over public education was, obviously, not

supportive toward HIV/AIDS surveillance and prevention efforts. To address this issue, in

1994, several international as well as local institutions initiated a regular program of training

for journalists to provide basic HIV/AIDS information and to encourage them to continue

training and advocacy among their colleagues at home (Mboi and Smith, 2006). These

campaigns aimed at reducing mis-perceptions among target group that AIDS only effects

promiscuous people or IDU, increasing target group awareness of the perceived level of

personal risk in relation to AIDS and increasing target groups knowledge of risk prevention

methods that would not further marginalize vulnerable groups. Television commercials, radio

advertisements, publications, talk shows, toilet door advertising strategy and writing

competitions were launched (Turk, 2001). The press coverage of HIV/AIDS over the years

showed some improvements including more frequent reporting, more varied subject matters,

and much broader geographical response to the field. Furthermore, with the increasing

number of articulate, HIV-positive people, more positive portrayals of people living with AIDS

balanced the earlier discouraging publications. However, serious problems remain. Some

coverage remains reactive and repetitive. There also remain to be sensational papers which

are negligent in their discussion of HIV/AIDS as well as their casual breach of the privacy

and rights of individual HIV-positive people, publishing names without consent and

increasing the chance of exposure to stigma and discrimination (Mboi & Smith, 2006) and

not using both-side covering principle, so that false perception on the HIV/AIDS remains

(Hudiono, 2005)

As revealed in IBBS 2007, 66% of Indonesian FSWs perceive that

they are at risk for HIV. Seventy four percent of FSWs in Indonesia learned HIV from

television and 81% learned from health workers. Only 32% of direct FSWs gain HIV

information from VCT counselors (MOH, 2009). These findings suggest that among FSWs,

the role of media and health workers in shaping their risk perception are more prominent

than VCT counselor’s is. However, this suspicion needs further exploration.

32

Perceived risk can also be shaped by sources other than mass media.

Among African-American population in the US with high HIV prevalence in the US, health

professional’s assessment shapes individual’s self-perception of risk for HIV. When health

professionals conclude that they are at moderate to high risk for HIV, the individuals will say

that they are so (Nunn, et al., 2011). In Thailand, peer educators are the trusted information

source for HIV risk and condom negotiation education among local FSWs (UNAIDS, 1999).

m. Social stigma

Stigma refers to “the identification that a social group creates of a

person (or group of people) based on some physical, behavioral, or social trait perceived as

being divergent from group norms” (Goffman, 1963). World-widely, stigma has been

recognized in sex work environment (Liu, et al, 2012). In regards to its existence, sex work in

Indonesia is not exceptional (Mboi & Smith, 2006), but it is still found to varying degrees in

Indonesia. For example, consider differing cultural attitudes about sex work in the city of

Jepara (Central Java, Indonesia) versus Malang (East Java). An International Labor

Organization (2004) study of child prostitution revealed that although money coming from

sex work was judged unacceptable, sex workers and their families in Jepara tended not to

be stigmatized. In contrast, their counterparts in Malang did. Also, the Jeparanese were

well accepted when attending Quran recitals while those living in Malang were not. Also, ex-

FSWs in Jepara could easily find husbands as they were rich in contrast to Malang ex-FSWs

who could not, although the latter are not less rich than their counterparts.

Possibly, the difference in attitudes between the two cities may be

explained by cultural tradition. In Jepara, a local myth tells of an ancient princess’s curse

that local girls would become temporary sex workers in their lives and those who worshiped

her on certain Javanese days would be given more clients - making sex work less

stigmatized (the International Labor Organization, 2004). Also parenting practices among

33

some West and Central Javanese involve nurturing young girls in such ways that earning

money through sex work is considered normal and not stigmatized. Women who bring

money from sex work to their parents are respected in the community (Koentjoro, 2004).

Ancient beliefs that may also contribute to the degrees of

stigmatization can be traced to other Javanese sub-cultures. In some Central and East

Javanese sub-cultures, for example, stigma has been attached for centuries on behaviors

related to the 5Ms: madon (concurrency practices), main (gambling), madat (opium

smoking), minum (alcohol drinking) and maling (stealing). Within this culture, however, the

degree of stigmatization varies according to the social strata. In the higher level

communities, madon (concurrency practice) has been accepted as an exhibition of power.

To show their power to others, the emperors of ancient Javanese kingdoms in the Hinduism

era, in addition to having empresses, had dozens of concubines (garwa ampil) who, in many

cases, came from as far as Indochina countries. The possession of women (wanita) was

seen as one attribute of being an affluent man besides wisma (house), kukila (birds),

turangga (horse, now it becomes cars) and curiga (weapon). Women were political gifts from

other kingdoms and subordinates to secure their own power and political positions. The

stigma attached to people in this strata involved in this practice is lesser than those in the

lower social economy status. The promiscuity practice as well as stigma stratification do not

totally diminish with the introduction of Islam. Persian and Gujarati spice traders in the 1400s

brought Islam to ancient Javanese kingdoms. The kings in the era practiced the leftish

Tantrayana (Vajrayana) and worshipped Siva, as depicted in ancient relics (Soekmono,

1995; Kinney, et al., 2003). In contrast to the rightist followers’ belief, the left-handed Tantric

followers believed that energy, including supernatural power, could be absorbed by

practicing alcohol drinking, ritual performed with corpses in the cremation ground and sexual

rites in the meditation (Biernacki, 2006; Zoetmulder in Widnya, 2008), involving sacred

women not necessarily ones’ formal wives. The rites were also practiced in initiation

34

ceremonies (Zoetmulder in Widnya, 2008). Kertanegara, an ancient East Javanese king, is

famous for his leftist Tantric practices to absorb power to protect his people (Purwita in

Widnya, 2008). The women involved in these ceremonies were usually respected.

The ancient Javanese kings mostly embraced Islam for political

reasons and maintained their prior religious practices, while Islam permeated

incomprehensively into the community (Rani, 2012). Javanese-muslim apostles in the

ancient era were opponents of the Five Ms, however, they chose to implement an

acculturation strategy using the long known arts and performances rooted from Hinduism,

such as Mahabharata characters and the local gamelan orchestra, to spread Islam.

Animism, syncretism and Hindusim practices among Javanese muslims could be noticed in

East Java back in the 20th century (Greetz, 1960) and can be easily found in East and

Central Java in these modern days. To some extent, the Javanese community still believes

that having more than one partner is normal for kings. For example, the modern Javanese

kings and sultans of the preserved Jogjakarta and Surakarta kingdoms in the 20th century

had more than one wives. The past and current kings of Jogjakarta, in particular, also are

widely believed by their people as having one mythical, immortal wife – the Goddess of the

Indian Ocean- whom they wed on the day they are crowned. As the kings of Jogjakarta

are/were formally the muslim leaders (Sayiddin Panatagama Kalifatullah) of his people, it

was not unusual that the kings in the past divorced and re-married their wives to maintain

themselves married to four wives as permitted by the Islamic law while keeping the

traditional Javanese value of masculinity and power. Outside the sultanate palaces within

the community, frequent questions about rich or powerful persons are usually surrounding

the second, third or fourth wives whom they have.

The Javanese have been the most people who encountered these

different culture introduction and assimilation for centuries, which in part shaped the

35

nowadays culture, including their views on sex work. The last of three and a half centuries of

Dutch colonialism in the past strengthened the existence of the ‘legalized’ prostitution

(Jones, Sulistyaningsih & Hull, 1998). The Japanese brief occupation is known for its forceful

promiscuous practices, involving thousands of ianfu (comfort women) of Indonesian descent

as well as interned Dutch women. Living in this mixed-culture situation, although generally

claim themselves as muslims, Javanese people are distinct from other muslims in Persia

and Gujarati, from whom they learned about Islam (Greetz, 1960; Rani, 2010). In the modern

Javanese setting, the people’s various acceptance levels of culturally embedded

concurrency as well as anti-concurrency practices may contribute to the community

confusion, different degrees of stigmatization and different degrees of female sex workers’

denial of their risk for HIV, an infection that was unknown in the past.

In other sub-culture as Balinese, the almost similar promiscuity

practices have also been identified. This is not surprising, as historically Balinese royal

family members and priests were Hindu-Javanese of the Kingdom of Mojopahit who fled to

Bali Island when they lost the battles against troops of Islamic kingdoms. In the Balinese

culture, low-caste widows without strong family support were the possession of kings. If the

kings chose not to include them as their family members, the widows were sent to operate

as prostitutes. Some amount of their income went to the kings (Jones, et al., 1998).

Although in parts Javanese and Balinese cultures allow promiscuity,

the systems did not contain the fully commercial sex principle, which was later introduced by

the Dutch colonial government. This system, however, has laid the foundations for the

commercial sex through valuing women as commodities (Jones, et al., 1998).

Different cultural contexts bring different levels of stigmatization to

sex– related work. A study in Nigeria showed that some “defensive coping mechanisms”

36

made sex workers perceive that they were not at risk for HIV acquisition. Defensive coping is

a mechanism developed by a person by making illusions of exaggerated perception of

control and unrealistic optimism that can help the person to adapt successfully to threatening

events. It is often characterized by rationalization of “failures” and projection of blame and

responsibility (Ankomah et al., 2011).

Within the cultural context of varying acceptance levels of sex work in

Indonesia, this study will examine whether stigma in this cultural environment actually

influences FSWs’s control belief against and perception on risk for HIV.

n. Other infections

Studies linked sexually-transmitted infections and the risk of getting

HIV through laboratory confirmation with or without mathematical modeling (Robinson et al.,

1997; Renton, et al., 1999; Fleming & Wasserheit, 1999; Grosskurth, et al., 2000; Nusbaum,

et al., 2004). So far, the link between the self-perceptions on getting STI and HIV has not

been observed.

D. Theoretical Framework: The Social Ecological Model

This study drew upon the Social Ecological Model as its theoretical framework. The

original model posits that individual developments are influenced by five societal levels

within which someone lives – individual/intrapersonal, interpersonal, organizational,

community and government (Simons-Morton, et al., 1988). This model was later modified by

Simons-Morton, McLeroy and Wendel (2012) to include seven societal levels by adding

physical environment and culture.

The modified model, as proposed by Simons-Morton et al. (2012), combines

principles drawn from several socio-cultural theories, models, and disciplines to form a

37

conceptual tool for guiding health promotion and education. The individual/intrapersonal

level of the model encompasses a person’s personal characteristics including knowledge,

attitudes, values, skills, behaviour, self-concept, self-efficacy, and self-esteem. The

interpersonal level includes the individual’s social support network, family, work group, peers

and neighbours. The organizational level incorporates shared norms, incentives,

organizational culture, management style, organizational structure and communication

networks. The community level covers the area of economics, community resources,

neighbourhood organizations, community competencies, social and health services,

organizational relationships, folk practices, governmental structures, formal leadership and

informal leadership. At public policy level the model takes into account legislation, policy,

taxes and regulatory agencies. The physical environment level consists of zoning

ordinances, built environment and population density. The culture level considers cultural

changes within the society. The Social Ecological Model’s seven levels are depicted below in

Figure 3.

38

Figure 3. The Social Ecological Model (Simons-Morton, McLeroy & Wendel, 2012).

The Social Ecological Model was selected to guide this study because it captures the

many levels of social influence within which brothel-based FSWs live. At the intrapersonal

level, brothel-based FSWs bring their own individual characteristics such as educational

background, migration history, cultural values, and beliefs about health and illness to their

role in selling commercial sex. At the interpersonal level, for example, brothel-based FSWs

in Jakarta have been found to form meaningful ties with other sex workers, their clients, and

local merchants such as electronic home equipment creditors and herb vendors

(Sedyaningsih-Mamahit, 2002). At the organizational level, FSWs interact with their brothel

managers around the commercial aspects of selling sex (Sedyaningsih-Mamahit, 2002).

They also participate in or are influenced by the activities of community organization such as

their brothel management organizations, Quran recital groups conducted by the local

department of social welfare, and Rukun Tetangga, Rukun Warga (Widianto, 2008). As in

Public Policy

Culture

Physical environment

Community

Organizational

Interpersonal

Intrapersonal

39

other non-brothel communities, Rukun Tetangga is a semi-formal organization chaired by a

man/woman elected through a democratic process by individuals. It serves about 30

households (brothels) by helping them resolve their social and population registration issues

such as identification card processing. Rukun Warga is a semi-formal organization

coordinating about 2-6 Rukun Tetanggas with more or less similar duties. The chair is

elected through the same process. Rukun Tetangga and Warga usually hold regular

meetings with individuals living within their areas. Rukun Warga functions as a bridge

between their members and the Kelurahan (the smallest unit of governmental office in

Indonesia).

Kelurahans in urban areas and villages in rural areas operate on both the community

and public policy levels. These organizations manage governmental programs for and the

legal affairs of citizens residing in several Rukun Warga. A Rukun Warga may be comprised

solely of non-brothel areas or combinations of brothel and non-brothel areas. Heads and

staff members of Kelurahan are government employees appointed by the city government.

Heads of villages are not government employees, and selected through direct elections and

paid by the people living in the particular areas, but having the same legal position as heads

of kelurahans. Kelurahan and villages are under the management of Kecamatan, a higher

level of government office, which duties include issuing identification cards and guaranteeing

the civil order. In several places in Indonesia, FSWs failing to show ID cards issued by any

Kecamatan in Indonesia may not have access to HIV prevention and treatment facilities

(Gorman, 2011). Street-based FSWs are subject to legal crackdowns on commercial sex by

the Satuan Polisi Pamong Praja, an apparatus of Kecamatan charged with maintaining

social orders in public places. Brothel-based FSWs working in brothel compounds typically

are not subject to the same legal enforcement. Social and health services also usually exist

at this organizational level.

40

The physical environment zoning policies at the city levels affect FSWs’ social life in

Indonesia to various degrees. Generally, public places such as parks, areas under the

bridges, and market surroundings are prohibited for commercial sex. Brothel compounds are

the only zones that are free of being cracked down upon by government apparatuses,

although this exception is widely criticized by religious leaders.

At the broadest level, distinct cultural environments based in part on ethnicity and

religion can be identified in Indonesian society, and they, to some extent, impact on FSW’s

existence. FSWs working and living close to Muslim communities have dual cultural

identities: they are “immoral women” when they are working and “Muslim women” when they

are reciting Quran. In terms of the latter, Muslim leaders for several decades generally have

demanded the closure of brothel localized areas. Friction erupts periodically in the form of

debates at the community and government levels, usually consistent in timing to a major

local or governor pre-election campaign. Pro- brothel compound advocates argue that

brothel closures will force FSWs to work on the street, thus inhibiting coordinated STI and

HIV controls. Those who are against- brothel compounds maintain that the practice

constitutes the legalization of immoral culture. At least three brothel brothel compounds in

three different provinces were closed in the 1990s and 2000s due to such a pressure.

E. Conceptual Framework

Drawing upon a review of the literature and the ecological model, the study built on

key variables representing the four original levels of the model (Simons-Morton et al., 1988):

individual/intrapersonal, interpersonal, organizational, community and government. The

levels of culture and environment which were added later would require additional data

collection that is beyond the scope of this dissertation. The conceptual framework of this

study is depicted in Figure 4.

41

Figure1.4 Conceptual framework

Figure 4. Conceptual framework of the study.

The Ecological Model as used in this study assumes that intrapersonal characteristics exert

a direct effect on self-perception of risk among FSW. For example, a sex worker who has

worked for many years in various brothels may be more likely to see herself at risk as the

result of multiple opportunities for exposure than a younger, neophyte to sex work.

However, a FSW’s perception that she knows enough about HIV (perceived knowledge) to

protect herself (perceived control) against infection can modify this direct effect. Peer

support for risk reduction at the intrapersonal level can heighten a FSW’s perceived control

over infection as can NGO support and brothel policies at the organizational level. At this

level, special task force on HIV prevention works in the brothel compounds, distributing free

condoms from the National AIDS Commission (Surabaya AIDS Commission, 2012). At the

Intrapersonal Level

Demographic Characteristics

Migration history

Level of HIV Knowledge

Sex work experience

condom use

Drug use and alcohol drinking

Self-

perceived risk

for HIV

acquisition

Interpersonal Level

Peer’s support

Organizational Level

Brothel manager’s support

NGO’s support

Community Level

Sources of HIV information

HIV/STI Counseling and testing

Social stigma

Perceived

control

over

becoming

infected

by HIV

Protective

action

against HIV

42

community level, obtaining accurate and trusted information about HIV can affect an FSW’s

perception that she is at risk for the virus along with her perception that she can control the

likelihood of infection through risk reduction measures. Beside screening and treating,

sexually transmitted infection (STI) clinics that also act as VCTs in some public health

centers have the task of preventing HIV among FSWs including risk sensitizations.

Perceived stigma can lower an FSW’s risk perception through coping mechanisms which

enhance her denial against stigma.

F. Brothel Compounds Situation in Surabaya

According to Basuki, Wolffers, Deville, Erlaini, Luhpuri, Hargono, Maskuri, Suesen,

van Beelen (2002), there were 3,500 FSWs living in six brothel compounds in Surabaya in

2002. In the PI personal communication with a Surabaya Health Office staffer (2011), it was

revealed that the number declined to 2,600 in 2011. In addition, this number may decline

over time because FSWs migrate from city to city nation-widely. Inside the brothel

compounds, sexual transactions are discussed and executed in brothels. In Surabaya,

brothels in slum areas can be surrounded by non-prostitution households that usually run

small food and grocery stalls. In brothels, FSWs are recruited and marketed by the brothel

managers. In return, the FSWs are required to pay some contribution to the managers for

housing, marketing and security services provided. On average, FSWs live and work in one

brothel for six months to one year. In 2010, the City of Surabaya government urged the

brothel compounds not to recruit new FSWs. Brothel compounds are now only allowed to

maintain the current FSWs.

In the Islamic months of Ramadhan, the brothel compounds close, and the FSWs are

supposed not to work to respect the Muslim community (private communication with a

Surabaya Health Office staffer and a local public health worker serving a prostitution brothel

43

compounds community, 2011). In reality, brothel-based FSWs move their commercial work

to boarding houses just outside the brothel compounds and become freelancers with higher

tariff, frequently 2-3 times as high as their regular brothel-based tariff (Surabaya Pagi,

August 22, 2011).

In HIV prevention, each the brothel compound partners with an NGO. These NGOs

have lists of brothels and FSWs in the corresponding the brothel compounds. For sampling

purposes, Table VIII summarizes the best information available on the characteristics of the

six the brothel compounds in Surabaya in 2012 – Dolly, Jarak, Dupak Bangunsari, Tambak

Asri, Sememi and Klakah Rejo.

TABLE VIII

CHARACTERISTICS BROTHEL COMPOUNDS OF JARAK, DOLLY, DUPAK

BANGUNSARI, TAMBAK ASRI, SEMEMI AND KLAKAH REJO, SURABAYA IN 2012

Dolly Jarak Dupak Bangunsari

Tambak Asri Sememi Klakah Rejo

Subdistrict (Kecamatan)

Sawahan Sawahan Krembangan Krembangan Benowo Benowo

Sex worker population in 2011*

497 648 274 509 212 91

Brothel manager population *

50 270 85 134 24 21

Local commitment on regular STI/HIV check-ups

Dolly = Jarak; each FSW visits VCT three monthly; each FSW screened for STD once/month**

Dupak Bangunsari: N/A Tambak Asri: N/A

Sememi = Klakah Rejo; each FSW visits stationary VCT or is visited by mobile VCT three monthly***

HIV cases detected Cumulative **** and ***** (in 2007-2011)= 328 2007: 95 2008: 72 2009: 46 2010: 16 2011: 99

N/A Cumulative ******(in 2007-2011)= 150

Note:

* = Badan Perencanaan Pembangunan Daerah Jawa Timur, 2011 [the East Java Provincial

Office for Development Planning]

** = Hartati, 2012

*** = Riamawati , 2010

**** = Hartati, 2011

***** = Hartati, 2012

****** = Riamawati, 2012

44

At the city level, the Surabaya Commission on AIDS supports the provisions of condom

vending machines within the brothel compounds. The commission provides the maps of the

prevalence HIV/AIDS in Surabaya. The PI adopted the map and added the locations of the

brothel compounds on it.

Figure 5. Distribution of people living with HIV/AIDS, the brothel compounds and health care services for HIV/AIDS in Surabaya.

Source: the Surabaya AIDS Commission (2012) (approximate location of brothel the

brothel compounds are added) Notes: Jumlah kumulatif ODHA (2009-2010) = cumulative numbers of people living with

HIV/AIDS Layanan kesehatan = health services

Methadon = methadone maintenance service LJASS = Layanan jarum suntik dan alat suntik steril = Exchange needle service IMS = Infeksi menular seksual = sexually transmitted diseases (clinic) VCT = voluntary counseling and testing CST = care, support and treatment PMTCT = prevention of mother-to-child transmission

brothel

compounds

45

II. METHODS

A. Aims of Study

1. General aim

This cross sectional study examined the influence of intrapersonal

characteristics, perceived control over becoming infected by HIV, and protective actions

against HIV on self-perception of risk for HIV among 155 brothel-based FSWs in Surabaya,

Indonesia

2. Specific aims

The specific aims of this study were:

A2.1 To investigate to what extent FSWs’ intrapersonal characteristics predict self-perceived

risk for HIV infection.

A2.2 To investigate to what extent perceived control over becoming infected by HIV predicts

self-perceived risk for HIV infection.

A2.3 To investigate to what extent taking protective actions against HIV predicts self-

perceived risk for HIV infection.

B. Hypotheses and Statistical Hypotheses

1. The main hypothesis

The main hypothesis of this study was, “FSWs who perceive that they have

more control over becoming infected through protective action are less likely to perceive

themselves at HIV risk.”

Perceived controls examined in this study were beliefs that certain protective

actions could protect them from HIV infection.

46

Statistical hypotheses for these perceived controls to be associated with self

perceived risk were:

Ho: β1 =0

Ha: β1 ≠ 0

in the regression model of: Logit [P (Y=1)]= β0 + β1(X1) where Ho, Ha, Y, β0 , β1, X1

respectively denoted the null hypothesis, the alternative hypothesis, self-perceived risk for

HIV, constant, the coefficient of regression and a particular perceived control for each

regression model.

2. Protective actions

Protective actions sub-variables examined in this study were using condom

with new clients, avoiding needle sharing, having shamans insert traditional implant,

practicing traditional rituals, bathing her own body before having sex, bathing client before

having sex, consuming antibiotics before having sex, washing her own vagina after having

sex, having others wash her vagina regularly, asking clients’ HIV statuses, and consistent

condom use. In the questionnaire, these actions were put in Section DxB, where x

representing the question number in the section. Statistical hypotheses for these protective

actions to be with associated self-perceived risk were:

Ho: β2 =0

Ha: β2 ≠ 0

in the regression model of: Logit [P (Y=1)]= β0 + β2(X2)

where Ho, Ha, Y, β0 , β2, X2 respectively denoted the null hypothesis, the alternative

hypothesis, self-perceived risk for HIV, constant, the coefficient of regression and a

particular protective action for each regression model.

47

3. Intrapersonal characteristics

Intrapersonal characteristics (being older, better educated, greater number of

work place, greater level of HIV knowledge, no alcohol drinking) will be positively associated

with increased perception of risk for HIV.

Statistical hypotheses for these intrapersonal characteristics to be associated

with self-perceived risk were:

Ho: β3 =0

Ha: β3 ≠ 0

in the regression model of: Logit [P (Y=1)]= β0 + β3(X3)

where Ho, Ha, Y, β0 , β3, X3 respectively denoted the null hypothesis, the alternative

hypothesis, self-perceived risk for HIV, constant, the coefficient of regression and a

particular intrapersonal characteristic for each regression model.

C. Setting

The study was conducted in six brothel compounds in the city of Surabaya, East

Java, Indonesia. The compounds in this study were Dolly, Jarak, Sememi, Klakahrejo,

Dupak Bangunsari and Tambakasri.

D. Study Population, Sampling Frame and Sample

1. Study population

This study population was all brothel-based female sex workers (FSWs) in the

brothel compounds of Bangunsari, Tambak Asri, Sememi, Klakah Rejo, Jarak and Dolly in

Surabaya, Indonesia. The exact real-time population size could not be obtained from the

record. The latest record was obtained 3 months prior to this study through a survey project

conducted by Yayasan Genta Surabaya – an NGO working with FSWs in Sememi and

Klakah Rejo - the brothel compounds within their jurisdiction. The Yayasan Hotline Surabaya

48

and Yayasan Abdi Asih did not have the updated population data and maps. The

last survey projects were funded by the government and conducted in 2009. In this case, the

population sizes of each of the 4 remaining brothel compounds were obtained from the latest

STD clinic reports. Based on the best data available, the population total size was 2,384. Of

the size, 497 were of Dolly, 648 of Jarak, 274 of Dupak Bangunsari, 509 of Tambak Asri,

212 of Sememi and 244 of Klakah Rejo.

2. Participant eligibility

To be eligible for the study, a prospective participant had to be female, 21

years of age or older, and working in a brothel compound in one of the six brothels for at

least the past three months. Participant exclusion criterium of this study was having tested

HIV positive at the last medical check-up.

3. Recruitment

For recruitment purposes, 3 non-governmental organizations (NGOs) agreed

to participate. The NGOs were Yayasan Hotline Surabaya, Yayasan Genta and Yayasan

Abdi Asih. Using the IRB-approved recruitment text, the NGOs invited FSWs working in the

compounds to participate in this study. The invitation was delivered in person and through

the telephone to all brothel-based FSWs. The FSWs who chose to participate in this study

were asked to come to the research headquarters or civic centers. To check whether a

particular FSW came from one of the compounds, the PI asked her to mention her brothel’s

name, address, neighborhood (Rukun Tetangga and Rukun Warga). The PI then checked

whether that address was within the compound with her previous observation of the

compound during her visit to the NGO’s office. The name of the NGO staff who contacted

the FSW and a description of their physical appearance also was asked of the prospective

participant. The PI met all the NGO staff who were assigned by the NGO to participate in this

study. Yayasan Abdi Asih did not hold the most updated lists for FSWs working in Dolly and

49

Jarak, but it submitted the map of both brothel compounds. The PI performed a similar

procedure to FSWs working in these two compounds and the compound map was used to

perform the cross-checking. Eligibility screening was conducted by the PI. Participants’

identities are stored by the PI in a locked cabinet for five years.

4. Sample size calculation

Before the study was conducted, a calculation to

obtain a sample size needed was performed. With the main hypothesis of “more correct

perceived control over becoming infected with HIV will be associated with lower perception

of risk for the virus acquisition”, the sample size calculation will be based on the odds ratio

for lower perception with every unit increase of more correct perceived control.

The sample size is calculated using the G*Power 3.1 Program developed by

Faul, Erdfelder, Buchner & Lang (2009) based on Demidenko’s (2007) approach to sample

size calculation for logistic regression analysis.

To calculate the sample size, information is needed on the probability of an

event occurs under the null hypothesis (P0), effect size intended - using either odds ratio or

the probability of an event occurs under the alternative hypothesis (P1), the confidence

interval and statistical power intended, and the proportion of participants estimated or

planned in each group (x parm π).

P0 = P(Y=1|x=0) is the probability of an FSW feels as at lower risk for HIV when she has

correct perceived control under H0

Odds ratio = OR = the ratio of the probability of being a direct FSW having correct perceived

control over becoming infected with HIV and the probability of having incorrect

50

perceived control over becoming infected with HIV to perceive herself as at lower

risk for HIV

In this study, an FSW had perceived control if she reported preventing HIV infection through

any means including but not limited to consistent condom use, avoidance of needle sharing,

susuk (traditional implant) use, bathing before having sex, antibiotics and/or herb

consumption, client filtering, dukun/shaman service use and religious rite practices.

As published data on P0 and OR of FSWs in Surabaya could not be found,

this study sample size calculation used a proxy indicator of consistent condom use for

correct perceived control based on findings in an Indian study of reported prior condom use

and current self-perceived risk of acquiring HIV (Jain, Saggurti, Mahapatra, Sebastian,

Modugu, Halli & Verma, 2011). Mobile FSWs recruited in the Indian study were street- and

brothel-based ones, both full and part-timers, while in the Indonesian 2007 national survey

full timers were considered as direct FSWs covering both street- and brothel-based ones. In

the Indian study, prior condom use with occasional client was measured with self-report on

consistent condom use in the past one week. In the Indonesian survey, consistent condom

use was measured in the same way. The Indian study findings are cited in Table IX.

51

TABLE IX

PERCENTAGE OF MOBILE FSWS ACCORDING TO THE DEGREE OF CONGRUENCE BETWEEN HIV RISK PERCEPTION AT INTERVIEW AND PRIOR CONDOM USE

BEHAVIOR WITH OCCASIONAL CLIENTS IN INDIA Congruence between current HIV risk perception and prior condom use with occasional clients Total (%)

I. Congruent 62.6

a. Consistent condom use and at low HIV risk 47

b. inconsistent condom use and at high HIV risk 15.7

II. Not congruent 36.4

a. Consistent condom use and at high HIV risk 24.1

b. inconsistent condom use and at low HIV risk 12.3

No client 0.8

Total (%) 100

N 5,413

Source: Jain, et al.(2011)

a. Odds ratio calculation of the Indian study findings

Excluding the ‘no client’ figure, the cross-table of consistent condom

use and HIV risk perception was drawn (see Table X).

TABLE X

HIV RISK PERCEPTION DISTRIBUTION BY CONDOM USE CONSISTENCY

HIV risk perception

Condom use consistency

Total

Yes No

Low 2,546 666 3,212

High 1,308 848 2,156

Total 3,854 1,514 5,368

In the Indian study, the odds ratio of being a mobile FSW consistently used condom is

2.5 times as likely as a mobile FSW inconsistently used condom to perceive herself as at

lower risk for HIV acquisition. This odds ratio was adopted for this proposed study.

52

b. P0 calculation for FSWs in Surabaya

The calculation of P0 for FSWs in Surabayan in this proposed study

was based on the Indonesian 2007 survey findings and the proportion of FSWs in the Indian

study reporting prior consistent condom use who perceived themselves as at lower risk. The

Indonesian survey findings are shown in Table XI.

TABLE XI

SELECT IBBS 2007 DATA FOR DIRECT FSW (BROTHEL- AND STREET-BASED) IN SURABAYA

Frequency of using condoms in the past one week % of direct FSWs

(%) never 3

(%) sometimes 39

(%) frequently 33

(%) always 24

Feels herself at risk for HIV infection 61

Source: the Ministry of Health of the Republic of Indonesia (2009a, pp. 82 and 84)

Among the Indian FSWs reporting consistent condom use, the proportion of those who

perceived themselves as at lower risk is = 2546/3854.

Assuming that the same proportion applied in the Surabaya setting, the probability that an

FSW in Surabaya reported consistent condom use and perceived herself as at lower risk

was estimated at 2546/3854 x 0.24 = 0.1585 rounded to 0.2. This was the value of P0 in this

calculation.

c. The expected fraction of FSWs perceiving themselves as

having control over becoming HIV infected

The fraction of FSWs in this study group expected to have

scientifically correct perceived control over becoming infected with HIV (π) was 40%,

53

assuming that the consistent condom use among direct FSWs - as the proxy indicator of

correct perceived control among brothel-based FSWs - in 2012 was slightly higher than the

2007 survey’s figure of 32% (MOH, 2009a).

d. Sample size calculation

In this study, a 2.5 increase in the odds of self-perception of at risk for

HIV to no-risk of HIV with every unit increase in the degree of perceived control, for a one-

tailed test with α =.05 and power of 80% was desired. The sample size calculation to yield

the proposed odds ratio was conducted using the G*Power 3.1 program. The statistical

hypothesis tested was:

Ho : β1 = ln(1) Ha: β1 = ln(2.5)

Below was the report:

Options: Large sample z-Test, Demidenko (2007) with var corr Analysis: A priori: Compute required sample size Input: Tail(s) = One Odds ratio = 2.5 Pr(Y=1|X=1) H0 = 0.2 α err prob = 0.05 Power (1-β err prob) = 0.8 R² other X = 0 X distribution = Binomial X parm π = 0.4 Output: Critical z = 1.6448536 Total sample size = 155 Actual power = 0.8012780

For the group of FSWs having correct perceived control, the sample size was 40% x 155 =

62.

For the group of FSWs having incorrect perceived control, the sample size was 60% x 155 =

93.

5. Sampling frame

Convenient sampling was applied to the study population to yield a desired

sample size.

54

6. Final sample

The participants of this study were 155 brothel-based FSWs who aged 21 and

over, and declared themselves as tested negative for HIV in the latest test or did not know

their HIV status, working at least for 3 months in the brothel compounds of Bangunsari,

Tambak Asri, Sememi, Klakah Rejo, Jarak or Dolly in Surabaya, Indonesia. Twelve

participants came from Dupak Bangunsari, 22 participants from Tambak Asri, 9 participants

from Sememi, 25 participants from Klakah Rejo, 50 participants from Jarak and 37

participants from Dolly.

E. Data Collection

The preparation for data collection began in June 2012. The main interviews were

conducted from July 7, 2012 and ended on July 17, 2012, three days before the month of

Ramadan began. The brothel compounds were closed temporarily on July 18, 2012 for the

entire month of Ramadan 2012.

1. Interviewer training

Fifteen research assistants who spoke English, Bahasa Indonesia, and

Javanese were recruited. English was needed in understanding the original questionnaire

and the research ethics material downloaded from the Collaborative Institutional Training

Initiative (CITI) website. Javanese was used in greetings and informal conversation between

interviews to gain participants’ deeper acceptance and trust. Bahasa Indonesia was used

mostly in the interview process. The research assistants’ educational background consisted

of one interviewer who had earned a Masters of Public Health degree and 14 with a

Bachelors of Medicine degree. All research assistants had research experience at the

bachelor levels. Under the 2007 curriculum currently applied in the school, bachelors of

medicine are required to pass the course of research ethics in their 2nd and 5th semesters in

Airlangga University School of Medicine, Indonesia and pass the school Institutional Review

55

Board (IRB) process for their final research project proposed. A certificate from the School of

Medicine Airlangga University on the assistants’ competence was obtained from the school.

The master of public health research assistant held an active IRB certificate from Emory

University. The research assistants were trained in interviewing techniques and recording of

responses.

A two-day training workshop was conducted before the data collection began.

During the training session, the questionnaire was explained and later on pilot-tested. The

workshop materials included an on-line tutorial provided by the Collaborative Institutional

Training Initiative (CITI) website. This website was accessed by the PI and the research

assistant holding the master of public health degree from Emory University.

2. Pilot-testing the questionnaire

Twelve sex workers, two from each of the six brothel compounds were

selected. These female sex workers were not included in the final study. The questionnaire

was pilot-tested in local civic centers and two karaoke rooms, which were neutral places for

the interviews. Based on the pilot-testing results, a few minor changes were made to open

ended questions to better adjust them to the brothel compound environment.

3. Data collection procedures

The main interviews with participants of Dolly, Jarak, Tambakasri and Dupak

Bangunsari were conducted at the research headquarter. The headquarter was located

adjacent to Dolly and Jarak, the two most populated brothel compound and was within 15-

minute ride from Tambakasri and Dupak Bangunsari, the two other brothel compounds. The

local civic centers (Balai Pertemuan Warga) within the Sememi and the Klakahrejo brothel

compounds were used for interviewing participants from the corresponding compounds.

56

Each interview was conducted in a private room where what was said could not be heard by

others. Written informed consents were obtained before the interviews began.

4. Compensation

Participants were monetarily compensated for their time and participation in

the study with $10.

F. Measures

Data were collected using a semi-structured questionnaire with both close-ended and

open-ended questions. A copy of the proposed instrument can be found in Appendix A.

Measured variables are discussed below.

1. The study’s dependent variables - self-perceived risk for HIV infection

To measure the perception of risk in this study, participants were asked: “How

likely are you to get HIV? Would you say that you are: (1) unlikely, (2) somewhat likely, or

(3) very likely?” The 1-3 Likert scales used were: ‘1’ for unlikely, ‘2’ for somewhat likely and

‘3’ for very likely.

2. The study’s main independent variable - perceived control over

becoming infected by HIV infection

Questions that were used to measure this variable were: ‘Can you protect

yourself from HIV infection if you...?’ The blank space was completed with specific protective

actions suggested by the PI. Binary answers of ‘yes’ and ‘no’ were provided for each

question. An open ended question was asked to the participants to explore whether there

were other control perceptions that had not been accommodated in the structured

questionnaire.

57

3. Mediator-protective action

The mediator variable of this study was taking “protective action” to avoid

becoming HIV infected. To measure the protective actions, participants were asked to self-

report on their personal behaviors that they had undertaken to prevent contracting the virus

through any means including but not limited to consistent condom use, avoidance of needle

sharing, susuk (traditional implant) use, bathing themselves before having sex, bathing

clients before having sex, antibiotics and/or herb consumption, dukun/shaman service use

and religious rites practices..

4. Other independent variables

Other independent variables of this study were clustered as intrapersonal

characteristics which were consisted of demographic characteristics, migration history, sex

work experience, condom use, level of HIV knowledge, and alcohol drinking. These

independent variables acted as controls.

G. Data Management

1. Data cleaning and quality control

Data cleaning was conducted in Surabaya under the principal investigator’s

(PI’s) supervision. At the end of each day, the PI cross-checked all the completed

questionnaires to ensure that all the questions were answered properly and clearly recorded.

2. Coding

Quantitative data coding was conducted by the PI. Data entry was conducted

in Surabaya by a research assistant under the PI’s direct supervision.

58

The ordinal scales of the self-perceived risk for HIV acquisition variable were

re-coded to binary ones. Scale ‘1’ represents ‘likely’ and scale ‘2’ represents ‘unlikely’ to

perceive risk for HIV acquisition.

Answers to open ended questions were translated into English and presented

to support arguments.

H. Data Analysis

Analyses followed standard statistical guidelines using descriptive statistics. Means

and their standard deviations were used for continuous variables and frequencies and

properties were used to study the distribution of categorical variables. For descriptive

analyses, the groups of respondents choosing scales other than 1 were compared using the

scales-1-group as the reference.

1. Multiple imputations for missing values for quantitative analyses

Missing values were identified from the data. After the re-coding completed,

multiple imputations (Tufis, 2008; Finch, 2010) using SPSS 20 was performed to fill in

missing values. The imputation method chosen was the fully conditional specification with 5

maximum iterations and the maximal percentage of missing values for each sub-variable

was 90 to anticipate the large missing values of condom use with foreigner clients. A

‘MAXMODELPARAM=100000’ term was used.

2. Hypothesis testing

The data used were the imputed ones. Prior to hypotheses testing, the

‘output’ was set to ‘split’ so that on the SPSS output the analysis results were split into 7

sections, which were the section of the original data, the sections of five iterated imputation

results and the section of the pooled results. As the independent and controlling variables

were of various measurement scales, all hypotheses were tested using two-tailed multiple

59

logistic binary regressions. The method chosen was ‘enter’ and the reference was the first

group. Each sub-variable was tested against one dependent variable at a time. Evaluation

on the data distribution normality was not needed for this specific kind of regression. The

testing was conducted at α=0.05, with confident intervals of 95%. The

statistical software used was SPSS version 20. The pooled significance levels of the

regressions were reported. As the SPSS version 20 only provides one-tailed test, the p

values shown on the output sections were divided by 2. At the end of analysis, all significant

predictors in the bivariate binary logistic regression analyses were entered simultaneously in

the multiple binary logistic regression analysis to establish statistical models. The variables

included in the bivariate analyses and their missing data are summarized in Table XII.

60

TABLE XII

SUMMARY OF THE DEPENDENT VARIABLE, INDEPENDENT VARIABLES, THEIR LEVELS OF MEASUREMENT AND THE MISSING DATA

Variable Level of measurement

Missing data

C: Self-perceived risk for HIV infection (dependent) Ordinal recoded to binary/ nominal

0

DxA: Perceived control over becoming infected by HIV independent) Binary/nominal

If use condoms with new clients 0

If avoid sharing injection needles (n=140) 15 (9.68%)

If have a shaman insert a traditional implant for a healthy life (susuk kesehatan) (n=116)

39 (25.16%)

If practice traditional rituals (n=136) 19 (12.26%)

If bathe herself before having sex (n=148) 7 (4.52%)

if bathe her clients before having sex (n=148) 7 (4.52%)

if take antibiotics before having sex (n=149) 6 (3.87%)

if wash your vagina after having sex (n=150) 5 (3.23%)

if you have others wash your vagina periodically (n=143) 12 (7.74%)

Ask clients for their HIV status (n=141) 14 (9.03%)

DxB: Protective Action (moderator) Ordinal

condom use with new client 2 (1.29%)

avoid sharing injection needle 6 (3.87%)

having shaman inserted traditional implant (susuk kesehatan) 5 (3.23%)

practicing traditional ritual 7 (4.52%)

bathing herself before having sex 2 (1.29%)

bathing clients before having sex 1 (.65%)

taking antibiotics before having sex 2 (1.29%)

washing her own vagina after having sex 2 (1.29%)

having others wash her vagina 4 (2.58%)

asking clients’ HIV status 2 (1.29%)

Intrapersonal characteristics (independent):

Demographic characteristics:

Age numeric 0

Ethnic group nominal 0

Highest level of education attained ordinal 0

Marital status nominal 0

Migration history:

Hometown nominal 0

Home province Nominal 0

Sex work experience

Length of work in the brothel Numeric 2 (1.29%)

Sex for money in the last Ramadan Nominal 0

Past workplace in the last 12 months Nominal

Karaoke bar (no=115, yes=40) Nominal 0

Bar/discotheque (no=138, yes=17) Nominal 0

Restaurants/food stall (no=140, yes=15) Nominal 0

Length of commercial sex work in Surabaya numeric 0

Number of workplace in the last 12 months numeric 0

Level of knowledge Numeric (score)

Can having sex with only one faithful uninfected partner reduce the risk of HIV transmission?

Nominal 6 (3.87%)

Can using condoms reduce the risk of HIV transmission? Nominal 1 (.65%)

Can a healthy-looking person have HIV? Nominal 8 (5.16%)

Can a person get HIV from mosquito bites? Nominal 6 (3.87%)

Can a person get HIV by sharing a meal with someone who is infected?

Nominal 6 (3.87%)

Alcohol use ordinal 0

Drug use ordinal 0

Number and type of clients numeric 8 (5.16%)

Condom use numeric 13 8.39%)

61

I. Protection of Research Participants

The UIC Institutional Review Board (IRB)’s final approval for the proposed research

was obtained on July 5, 2012. The Faculty (School) of Medicine IRB of Airlangga University–

a US-Office-of-Human-Research-Protection (OHRP) certified IRB in Surabaya – approved

the research proposal in Bahasa Indonesia on July 3, 2012. The certificate numbers for this

institution are IRB00008637, IORG0007197 and FWA00018525.

Permission to conduct the study in the area was obtained from the Badan Kesatuan

Bangsa dan Perlindungan Masyarakat (Department of Social and Political Affairs) of the City

of Surabaya on June 7, 2012, numbered 185/ H3.1.1/ I KM-KP1 2012.

Before the interviews were conducted, the purpose of the study was carefully

explained to the participants. It emphasized that the information collected from them would

be treated with maximum confidentiality. Participants wrote their own identities on the

consent sheets and signed the sheets after the purpose and future benefits of the study of

the Surabaya community and brothel-based female sex workers at large were explained.

The participations in the study were entirely voluntary, and prospective participants

were assured that they could decline to participate without penalty or loss of any services

that they might be receiving. They were also informed that they were free to decline to

answer any questions that they chose not to answer and that they could withdraw

themselves from the study at any time without penalty.

To protect the confidentiality of data, questionnaires and interview forms did not

include personal identifiers; instead, a study code number was assigned to each participant.

The digitally audio-recorded interviews were also de-identified and study code numbers were

assigned to each interview. The audio-recorded interviews are kept in a locked cabinet and

would be destroyed five years after all transcriptions have been completed. All identifiers

were blocked out of the transcribed versions of the interviews. All publications resulting from

the study would appear without participants’ names or information that would identify them.

62

III. RESULTS

To recap, this study examined brothel-based FSWs’ self-perceived risk for HIV infection and

its influencing factors. The study is guided by the social ecological framework (Simons-

Morton, McLeroy & Wendel, 2012) that was described in its entirety in Chapter One. The

model as adapted for this study includes three sets of analytic constructs:

Intrapersonal level variables include the women’s demographic background along

with their past and current experiences with sex work, substance use, HIV knowledge

and overall self-perceived susceptibility for disease.

Perceived control over becoming infected by HIV was measured by asking the

women whether or not they perceived that one or more of 10 scientifically

recommended or Indonesian traditional methods are effective in preventing HIV.

Protective Action against HIV refers to the women’s actual use of such preventive

methods to avoid acquiring the virus.

The study’s social ecology framework as initially conceived in chapter one proposed that

both intrapersonal level variables and women’s perceived control over becoming infected

through taking preventive actions directly affect FSWs’ self-perceived risk from HIV. The

framework further posited that women with greater perception of having control over

becoming infected through protective action would be the more likely than their peers to

actually employ these actions. Figure 6 shows the analytical framework of this study.

63

Figure 6. Analytical Framework

Chapter III is organized into seven parts. Part A describes self-perceived risk for HIV. Part B

examines the intrapersonal characteristics of the sample and the possible association

between intrapersonal characteristics and self-perceived risk for HIV. Part C describes self-

perceived control over becoming infected and examines its possible association with self-

perceived risk for HIV. Part D describes protective actions that FSWs reported they used to

avoid HIV and examines a possible relationship between their use and self-perceived risk for

HIV. Part E uses multiple binary logistic regressions to examine the influence of all

significant variables from all 3 analytic constructs (intrapersonal level, perceived control over

becoming infected, and protective actions taken) on self-perception of risk for HIV. Part F

reexamines the theoretical model that guided the study, and reconceptualizes it based on

the study’s findings. PART G turns to other results obtained from the qualitative data that

were collected as part of the study.

Intrapersonal Level Variables

Demographic Characteristics

Migration history

Sex work experience

Drug and Alcohol use

Level of HIV Knowledge

Self-perceived susceptibility for diseases

Perception on peer’s risk for HIV

Self-

perceived

Risk for

HIV

Perceived

control

over

becoming

infected

by HIV

Protective

Action

taken

against HIV

64

A. Part A: Self-perceived Risk for HIV (the Study’s Dependent Variable). Self-

perceived Risk for HIV

Participants were asked to self-report their perception of risk for HIV. Most FSWs

(68.3%) perceived that they were at some risk for the infection, with almost 48% perceiving

that they were very likely to become infected (Table XIII).

TABLE XIII

DISTRIBUTION OF SELF-PERCEIVED RISK FOR HIV (N=155) Self-perceived risk for HIV infection Frequency

Unlikely 49 (31.6%)

Somewhat likely 32 (20.6%)

Very likely 74 (47.7%)

Total 155 (100%)

In the descriptive statistics above, frequencies for HIV self-perceived risk are reported in the

item’s original categories. In conducting the binary and multiple regression analyses

throughout the rest of this chapter, HIV self-perceived risk has been recoded as a binary

variable in which “unlikely” is coded as “1;” “somewhat likely” and “very likely” were

merged and coded as “2” to form the response category of “likely.”

B. Part B: Intrapersonal Level Characteristics and Self-perceived Risk for HIV

1. Demographic characteristics of the sample

The participants’ age mean + SD was 34.10+7.348 years and median was 34

years. Most participants (84%) had achieved some education from elementary school (47%)

through junior high school (37%). Participants were asked to self-report the ethnic group to

which they felt they belonged. Most participants (86.5%) reported that they were Javanese.

Almost all of the participants (94.2%) had experienced marriage, but most were currently

65

divorced (61%) or widowed (19%). Table XIV presents the frequency distribution of FSWs’

demographic characteristics by age, education, ethnic group, and marital status.

TABLE XIV

DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS WORKING IN THE BROTHEL COMPOUNDS OF DUPAK BANGUNSARI, TAMBAK ASRI, SEMEMI, KLAKAH REJO,

DOLLY AND JARAK, SURABAYA (N=155) Demographic characteristics

Frequency

Age (yrs)

< 31 55 (35.5%)

31 – 40 71 (45.8%)

41 – 50 26 (16.8%)

51+ 3 (1.9%)

Highest level of education

< junior high school 81 (52.3%)

At least junior high school 74 (47.8%)

Ethnic group

Javanese 134 (86.5%)

Madurese 13 (8.4%)

Sundanese 3 (1.9%)

East Nusa Tenggara 3 (1.9%)

Hybrid 2 (1.3%)

Marital status

Never married 9 (5.8%)

Married not living together 21 (13.5%)

Divorced 95 (61.3%)

Widow 30 (19.4%)

2. Migration history

To assess the women’s migration history, participants were asked about the

province to which they returned home on major religious holidays – Idul Fitri and Christmas.

Most (87.8%) of the women reported being from Surabaya, but a few (12.3%) had migrated

66

from one of 6 other provinces and from one of an overall total of 36 different cities in

Indonesia. The 36 cities plus Surabaya were classified for analysis as being either urban or

rural areas. Five big cities in Java – Surabaya, Malang, Yogyakarta, Semarang and

Bandung - were classified as urban areas. These cities have or have had brothel

compounds similar to those in this study. The remaining locations were classified as rural

areas (Table XV).

TABLE XV

DISTRIBUTION OF BROTHEL-BASED FSWS’ HOME PROVINCES

AND URBAN VERSUS RURAL HOME TOWNS (N=155)

Places that were considered homes Frequency

Home province

Central Java 10 (6.5%)

East Java 136 (87.7%)

East Nusa Tenggara 1 (.6%)

Special Province of Yogyakarta 2 (1.3%)

West Java 5 (3.2%)

West Kalimantan 1 (.6%)

Home Town

Urban 33 (21.3%)

Rural 122 (78.7%)

3. Sex work experience

a. Length of time engaging in commercial sex work within the

brothel compounds from which the sample was recruited

Participants were asked about the length of time that they had

engaged in commercial sex in the brothel compound from which they had been recruited. Of

153 women answering the questions, the minimum length of time was 3 months and the

67

maximum length was 20 years (240 months) with a mean of 29.25 + 32.8 months and a

median of 20 months. In addition, participants were asked as to how long they had engaged

in commercial sex in the brothel from which they had been recruited (see Table XVI).

TABLE XVI

LENGTH OF TIME ENGAGING IN COMMERCIAL SEX IN THE RECRUITMENT COMPOUNDS

Variable 3-6 months 7-12 months > 13 months Total # out of N=155

Length of time selling sex in recruitment brothel (months) 20 (12.9%) 34 (21.9%) 99 (63.9%) 153 (98.7%)

b. FSWs’ experience of selling sex outside the brothel compound in

the last 12 months

Almost half of the participants (49.7%) also had experience with

selling sex outside the brothels in the last 12 months. Table XVII shows the distribution.

TABLE XVII

DISTRIBUTION OF FSWS’ WORKPLACE IN THE LAST 12 MONTHS (N=155) Type of workplace in the last 12 months Yes No

Karaoke bar 40 (25.8%) 115 (74.2%)

Bar/discotheque 17 (11%) 138 (89%)

Restaurant/food stall 15 (9.7%) 140 (90.3%)

68

c. Engaging in commercial sex for money in the last Ramadan

Brothel compounds close in the holy month of Ramadan. This annual

holy period for Muslims may last 29 or 30 days, depending on the visual detections of the

crescent moon. During fasting from sunrise until dusk in this month, Muslims abstain from

consuming food, drinking liquids, smoking and sexual relations. However, 11.6% of the

sample reported that they continued their sex work in the Ramadan of 2011 although the

data do not report if this exchange occurred during the day during fasting or in the evening.

4. Alcohol drinking and drug use

Alcohol drinking was not unusual in karaoke bars inside the brothel

compounds (53.5%). Some participants’ main job was ‘mbandari’ (pour alcohol for and

accompanied guests) in the karaoke bar in the brothels where they worked for a commission

of Rp. 1,000.00 (10 cents US dollar) per bottle sold. If the woman agreed, sex transactions

could follow. Table XVIII presents the frequency distribution of alcohol drinking in the last 3

months.

TABLE XVIII

ALCOHOL DRINKING BEFORE SEX IN THE LAST 3 MONTHS Frequency of alcohol drinking before sex in the last 3 months Frequency

Never 72 (46.5%)

a few times 48 (31.0%)

Frequently 35 (22.6%)

Total 155 (100.0%)

69

None of the participants reported using or injecting drugs despite one participant’s claim that

many FSWs use amphetamines prior to selling sex to boast their self-confidence in offering

their service. This particular participant admitted that she worked in the past delivering

packages of drugs by motorcycle within the brothels for a drug dealer.

5. Level of HIV knowledge

The women’s level of knowledge about HIV was assessed using the 5

standardized questions recommended by the UNAIDS for use with sex workers. Most

women had at least some knowledge of HIV. The sample’s score mean was 2.95, the

median was 3, and the mode was 3. Eight (5.2%) of the 155 women correctly answered all

five items, and only one participant (.6%) answered all 5 items incorrectly. The distribution of

FSWs’ level of HIV knowledge is presented in Table XIX.

TABLE XIX

FSWS’ LEVEL OF HIV KNOWLEDGE Level of knowledge Frequency

0 1 (.6%)

1 15 (9.7%)

2 33 (21.3%)

3 56 (36.1%)

4 42 (27.1%)

5 8 (5.2%)

Total 155 (100%)

6. Self-perceived susceptibility to disease

a. Self-perceived risk for different diseases

One limitation of merely asking participants about their perception of

risk for HIV is that their answer does not indicate to what extent their response mirrors or

70

compares with their perception of risk for other illnesses or disease. To help place their

perception of risk for HIV within a larger, personal context, participants also were asked to

report their perceived likelihood for acquiring four other common infections that FSWs

encounter: Dengue hemorrhagic fever, gonorrhea, syphilis, and common cold. Dengue

haemorrhagic fever was included as a comparison variable because it is a serious health

problem that is endemic to Surabaya (Yotopranoto, Kusmartisnawati, Mulyatno and Arwati,

2010). Gonorrhea and syphilis were examined because, like HIV, they are sexually

transmitted diseases. Also, brothel-based female sex workers in Surabaya have been the

targets of sexually transmitted infection control and condom use promotion efforts for more

than 3 decades, and this attention may heighten their perception of risk for gonorrhea,

syphilis, and HIV. Common cold was included as a variable because it is something that

most people acquire at some time but, unlike the other diseases, it is not serious and does

not require treatment. Table XX compares participants’ self-perceived risk for HIV with their

self-perceived risk for these four infections.

TABLE XX

COMPARISON OF SELF-PERCEIVED RISK FOR 5 INFECTIONS Infection Self-perceived risk Total

Unlikely Somewhat likely Very likely

Dengue haemorrhagic fever (DHF)

46 (29.7%) 40 (25.8%) 66 (42.6%) 152

Gonorrhoea 47 (30.3%) 34 (21.9%) 67 (43.2%) 148

Syphilis 45 (29%) 34 (21.9%) 71 (45.8%) 150

Common cold 13 (8.4%) 52 (33.5%) 89 (57.4%) 154

HIV 49 (31.6%) 32 (20.6%) 74 (47.7%) 155

b. Associations between self-perceived risks for HIV and other

diseases

Is increased perception of risk for acquiring one or more of the four

diseases above individually associated with increased self-perception of risk for HIV? To

71

address this question, responses to each of the five infectious diseases were recoded as a

dichotomous variable: “unlikely” versus “likely” (constructed by combining somewhat and

very likely). A set of bi-variate binary logistic regression analyses was conducted to test for

a possible association between self-perception of risk for each of the 5 infections and self-

perception of risk for HIV with unlikely to get infected by HIV as the reference category

(Table XXI below).

TABLE XXI

RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSION ANALYSES OF SELF-PERCEIVED RISK FOR HIV ON SELF-PERCEIVED RISK FOR OTHER INFECTIONS

Self-perceived risk for

B S.E. p OR

95% C.I.for OR

Lower Upper

DHF: unlikely (n=49)(#

, likely (n=106) 1.346 .389 .001* 3.841 1.792 8.233 HIV: unlikely (n= 81)

(#, likely (n= 74 )

Gonorrhea: unlikely (n=54) (#)

, likely (n=101) 1.869 .395 <.001* 6.481 2.986 14.067

HIV: unlikely (n= 81)(#

, likely (n= 74 )

For syphilis: unlikely (n=50) #

, likely (n=105) 2.601 .481 <.001* 13.477 5.253 34.580

HIV: unlikely (n= 81)(#

, likely (n= 74 )

For common cold: unlikely (n=14)#, likely (n=141)

1.190 .679 .080 3.286 .868 12.448 HIV: unlikely (n= 81)

(#, likely (n= 74 )

# = unlikely as reference * = statistically significant

No association was found between perceived likelihood of acquiring a

common cold and perceived likelihood of contracting HIV. Self-perceived risk for each of the

two venereal infections, however, was positively associated with increased self-perceived

risk for the virus. Possibly, FSWs closely associate gonorrhea, syphilis and HIV with each

other according to their shared sexual route of transmission and the similarity of community

72

prevention efforts. Also, STD clinics similarly screen for all 3 infections. The positive

association between increased self-perceived risks for HIV and DHF is puzzling. One

hypothesis is that FSWs erroneously believe that HIV is spread by mosquitoes in the same

way as is Dengue. Although 36.3% participants mistakenly believed that HIV is spread by

mosquito bites as indicated by an item in the study’s knowledge scale, no statistically

significant correlation was found between this belief and their perception of risk of getting

HIV.

FSWs’ perception on their peer’s risk for HIV infection and its

association with FSWs’ self-perceived risk for HIV was examined by conducting bivariate

binary logistic regressions. The association was significant. The results are shown in Table

XXII.

TABLE XXII

RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSION ANALYSES OF SELF-PERCEIVED RISK FOR HIV (NUNLIKELY = 78 NLIKELY =70) ON FSWS’ PERCEPTION OF

PEER’S RISK FOR HIV

Independent variable B S.E. p OR

95% C.I.for OR

Lower Upper

Perception of peer’s risk for HIV

1.523 .443 .001* 4.587 1.926 10.924 Unlikely (n=37)

Likely (n=111)

* = statistically significant

7. Logistic regressions examining the possible association between

intrapersonal level characteristics and self-perceived risk for HIV

The set of analyses meets AIM 1 of the study: To investigate to what extent

FSWs’ intrapersonal characteristics predict self-perceived risk for HIV infection.

73

a. Bi-variate binary logistic regression analyses of self-perceived

risk for HIV on intrapersonal characteristics

Bi-variate binary logistic regression analyses on intrapersonal

characteristics were conducted individually on intrapersonal level characteristics to examine

the association between demographic characteristics and self-perceived risk for HIV. Pooled

values were taken as the final results of the bi-variate analyses. Age was entered as a

continuous variable. The level of education, ethnic groups and marital status were coded as

nominal variables. Table XXIII shows the results of the bi-variate regressions.

74

TABLE XXIII

RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV (NUNLIKELY=49, NLIKELY=106, UNLIKELY AS REFERENCE) ON

INTRAPERSONAL CHARACTERISTICS OTHER THAN SELF-PERCEIVED RISK FOR INFECTIONS

Intrapersonal characteristics B S.E. p Unadjusted

OR

95% C.I.for OR

Lower Upper

Age (n=155) -.049 .023 .033* .952 .911 .996

Education:

Less than junior high school (n=81), reference

Junior High/equivalent and higher (n=74) .698 .327 .033* 2.010 1.059 3.813

Ethnic group

Javanese (n=134), reference

Non Javanese (n=21) -.228 .474 .630 .796 .315 2.014

Marital status

divorced (n=30), reference

Widowed (n=95) -.511 .426 .230 .600 .261 1.382

Other (n=30) -.511 .426 .230 .600 .261 1.382

Hometown

urban (n=33), reference

Rural (n=122) .273 .396 .491 1.313 .604 2.854

Home province

East Java (n=136), reference

Outside East Java (n=19) .980 .523 .061 2.664 .956 7.422

Length of work in the brothel

<1 year (n=46), reference

1 year and more -.253 .352 .473 .777 .389 1.549

Sex for money in the last Ramadan

.355 .504 .482 1.426 .531 3.831 No (n=137), reference

Yes(n=18)

Workplace in the last 12 months (no as reference)

Bar/discotheque (no=138, yes=117) 1.412 .597 .018* 4.102 1.273 13.217

Karaoke Bar (no=40, yes=115) .393 .369 .287 1.481 .719 3.052

Restaurants/food stall (no=140, yes=15) -.048 .545 .930 .953 .328 .2772

Number of workplace in the last 12 months (n=155) .252 .189 .183 1.286 .888 1.864

Exchange sex for money in other cities

.555

.488

.256

1.742

.669

4.535

no (n=135), reference

Yes (n=20)

Level of knowledge -.073 .151 .631 .930 .691 1.251

Alcohol use

.039 .322 .904 1.040 .553 1.956 no (n=72), reference

Yes (n=83)

* = statistically significant

75

The results of bi-variate binary logistic regressions of self-perceived

risk for HIV reveal that the older an FSW was, the less likely she was to perceive herself at

risk for HIV. Graduates of junior and senior high school were two times more likely to

perceive themselves at risk for the virus than those with less education. Marital status was

not significantly associated with self-perceived risk for HIV; neither was migration history.

Women who engaged in sex in the last six months at a bar/discotheque outside the brothel

compound where they were employed were more likely to see themselves at HIV risk than

those who did not. As reported earlier (Table 3.9), both increased perception of risk for

gonorrhea and syphilis were associated with increased self-perceived risk for HIV possibly

because government clinics and information programs stress that these diseases are

similarly acquired.

b. Binary logistic multiple regression analyses of self-perceived risk

for HIV on intrapersonal characteristics

Binary logistic multiple regression analyses of self-perceived risk for

HIV were conducted on all intrapersonal characteristics with p values less than 0.2 in prior

bivariate regressions analyses (see Table XXIII). Only self-perceived risk for syphilis and for

gonorrhea were statistically significant. The results are shown in Table XXIV.

76

TABLE XXIV

BINARY LOGISTIC MULTIPLE REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV (NUNLIKELY=49, NLIKELY=106, UNLIKELY AS REFERENCE) ON

INTRAPERSONAL CHARACTERISTICS

Intrapersonal characteristics B S.E. P Adjusted OR

95% C.I.for OR

Lower Upper

Age -.018 .029 .534 .982 .928 1.040

Education: < junior high school (n=81), reference .309 .424 .466 1.362 .593 3.128 At least junior high school (n=74)

Home province: East Java (n=136), reference 1.222 .755 .106 3.395 .773 14.918 Outside East Java (n=19)

Work in bar/discotheque in the last 12 months 1.389 .757 .067 4.012 .909 17.703

No (n=138), reference

Yes (n=17)

Self-perceived risk for :

Gonorrhea: unlikely (n= 54), reference 1.206 .538 .025* 3.340 1.163 9.587

Likely (n=101)

Syphilis: unlikely (n= 50), reference 1.579 .595 .008* 4.848 1.511 15.559

Likely (n=105)

dengue hemorrhagic fever (DHF): unlikely (n= 49), reference .699 .540 .195 2.012 .699 5.796 Likely (n=106)

Perception on peer’s risk for HIV: unlikely (n= 44), reference .591 .550 .282 1.806 .615 5.308 Likely (n=111)

* = statistically significant

C. Part C: Self-perceived Control over Becoming Infected by HIV

This set of analyses meets AIM 2 of the study: To investigate to what extent

perceived control over becoming infected by HIV predicts self-perceived risk for HIV

infection.

1. The distribution of self-perceived control over becoming infected by HIV

Self-Perceived-control over Becoming Infected by HIV was measured with

one item: “Can you protect yourself from HIV infection if you… (one of ten actions listed in

the questionnaire)?” The results suggest that most FSWs did not perceive that traditional

practices (having a shaman insert an implant or practicing traditional rituals) were effective in

preventing HIV infection. Almost half the sample believed that standard hygienic practices of

77

bathing self and clients prevented HIV. About 72% believed that washing your vagina after

sex was protective as well as about a third of the women believing that having someone else

periodically what their vagina would reduce their likelihood of becoming infected. The belief

that taking antibiotics is effective to avoid HIV was common (66.4%). Possibly this belief

stems from the frequently held association of perceived-risk for HIV with gonorrhea and

syphilis (Table 3.29). Surabaya STD clinics employ a periodic presumptive treatment

program in which all FSWs are routinely treated with antibiotics, a conception of which was

extended to the use of over-the-counter antibiotics for prevention of venereal disease, and

later on extended to HIV prevention. The use of over-the-counter antibiotics within the

brothel surroundings was also examined by Hadi et al (2010). The frequency distribution of

FSWs’ responses is shown in Table XXV.

TABLE XXV

DISTRIBUTION OF PERCEIVED-CONTROL OVER BECOMING INFECTED BY HIV

AMONG RESPONDING FSWS

Variable No Yes

If use condoms with new clients (n=155) 7(4.5%) 148 (95.5%)

If avoid sharing injection needles (n=140) 20 (14.3%) 120 (85.7%)

If have a shaman insert a traditional implant for a healthy life (susuk kesehatan) (n=116)

105 (90.5%) 11 (9.5%)

If practice traditional rituals (n=136) 123 (90.4%) 13 (9.6%)

If bathe herself before having sex (n=148) 84 (56.8%) 64 (43.2%)

if bathe her clients before having sex (n=148) 77 (52.0%) 71 (48.0%)

if take antibiotics before having sex (n=149) 50 (33.6%) 99 (66.4%)

if wash your vagina after having sex (n=150) 37 (23.9%) 113 (72.9%)

if you have others wash your vagina periodically (n=143) 105 (67.7%) 38 (24.5%)

78

2. Bivariate binary logistic regressions of self-perceived risk for HIV on

perceived control were conducted for each variable individually

Results from the bivariate binary logistic regression indicated that taking

antibiotics before sex and washing one’s vagina after having sex were the only variables

associated with reduced self-perceived HIV risk (Table XXVI).

TABLE XXVI

RESULTS OF BI-VARIATE BINARY LOGISTIC REGRESSION OF SELF-PERCEIVED

RISK FOR HIV ON PERCEIVED CONTROL

Perceived control B S.E. p Unadjusted

OR

95% C.I.for OR

Lower Upper

If use condoms with new clients (no=7, yes=148) -.396 .781 .612 .673 .146 3.113

If avoid sharing injection needles (no=28, yes=127) -.110 .418 .792 .896 .395 2.030

If have a shaman insert a traditional implant for a healthy life (susuk kesehatan) (no=136, yes=19)

-.017 .490 .972 .983 .376 2.571

If practice traditional rituals (no=132, yes=23) -.412 .461 .372 .663 .268 1.637

If bathe herself before having sex (no=88, yes=67) -.530 .328 .107 .589 .309 1.120

if bathe her clients before having sex (no=79, yes=76) -.550 .325 .090 .577 .305 1.090

if take antibiotics before having sex (no=50, yes=105) -.732 .350 .036* .481 .242 .955

if wash your vagina after having sex (no=38, yes=117) -.832 .385 .031* .435 .205 .925

if have others wash your vagina periodically (no=116 yes=39)

-.223 .373 .549 .800 .385 1.660

* = statistically significant no as reference

3. Binary logistic multiple regressions of self-perceived risk for HIV on

perceived control

Using the cut point of 0.2 for p values, bi-variate multiple logistic regressions

was performed on all perceived controls with p values not exceeding the value. The results

are shown in Table XXVII below. Only the variable “if wash own vagina after having sex”

remained and was statistically significant.

79

TABLE XXVII

RESULTS OF BINARY LOGISTIC MULTIPLE REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV ON PERCEIVED CONTROL (NUNLIKELY =81, NLIKELY =74, UNLIKELY AS REFERENCE)

Perceived control B S.E. p Adjusted

OR

95% C.I.for OR

Lower Upper

If bathe herself before having sex with clients (no=38, yes=117, no as reference)

Removed by backward LR if bathe her clients before having sex (no=79,yes=76, no as reference)

if take antibiotics before having sex (no=50, yes=105, no as reference)

if wash own vagina after having sex (no=38, yes=117, no as reference) -.832 .385 4.673 1 .031 .435

* = statistically significant

D. Part D: Examination of the Relationship Between Taking Protective Action and

Self-perceived Risk for HIV

This set of analyses meets AIM 3 of the study: To investigate to what extent is taking

protective actions against HIV predict self-perceived risk for HIV infection.

1. Distribution of protective actions taken against acquiring HIV

Protective action was measured using one parent question with 9 sub-items:

“In the last 30 days, how often did you …. (one of ten actions listed in the questionnaire)?”

Sharing needles was dropped from the following analysis for irrelevance as none of the

FSWs reported injection drug use.

a. Frequency distribution of consistent condom use

Table XXVIII shows the frequency of consistent condom use with total

clients in the last 7 days. The women reported approximately equal consistent versus

inconsistent use.

80

TABLE XXVIII

CONSISTENT CONDOM USE AMONG TOTAL CLIENTS IN THE LAST 7 DAYS Condom use consistency among total clients Frequency

Not consistent 73 (49.7%)

Consistent 74 (50.3%)

Total 147 (94.8%)

This study also explored consistent condom use with new clients in the last 30 days.

Table XXIX shows the distribution.

TABLE XXIX

CONDOM USE AMONG NEW CLIENTS IN THE LAST 30 DAYS Condom consistency among new clients Frequency

Not consistent 87 (56.1%)

Consistent 66 (42.6%)

Total 153 (94.8%)

With goodness of fit test, it revealed that there were differences in the proportions of condom

use among total clients and new clients (X2=43.351, df=1, p <.001). This finding confirms

that some returning clients also consistently used condoms.

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b. Bivariate binary logistic regressions of self-perceived risk for HIV

on condom use

Relationships between condom use and self-perceived risk for HIV are

shown in Table XXX. Consistent condom use in general was statistically signficiant, but with

new clients specifically was not.

TABLE XXX

RESULTS OF BIVARIATE BINARY LOGISTIC REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV (NUNLIKELY=81, NLIKELY=74, UNLIKELY AS REFERENCE) ON CONDOM USE

Independent variable B S.E. p Unadjusted OR

95% C.I.for OR

Lower Upper

Consistent condom use (no=81, yes=74, no as reference) -.988 .332 .003* .372 .194 .714

Condom use with new clients (never = 4, do=151, never as reference)

-.093 1.013 .927 .911 .125 6.639

*= statistically signifcant

2. Frequency distribution of methods other than condom use

Methods that the women reported using to protect themselves against HIV

include traditional protective practices common to Indonesia along with hygienic practices,

asking clients about their HIV status, and using antibiotics prior to sex. Traditional practices

were less practiced than any other protective actions, while washing own vagina after having

sex was the most frequent protective action practiced in the last 30 days with 84.9%

participants always performed it (see Table XXXI).

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TABLE XXXI

DISTRIBUTION OF PROTECTIVE ACTIONS OTHER THAN CONDOM USE TAKEN IN THE LAST 30 DAYS AGAINST HIV INFECTION

Protective action n Frequency of protective actions in the last 30 days

Never Sometimes Frequently Always

having shaman inserted traditional implant (susuk kesehatan)

150 148(98%) 0 1 (0.7%) 1 (0.7%)

practicing traditional ritual 148 137(88.4%) 8 (5.2%) 2 (1.3%) 1 (0.6%)

bathing herself before having sex 153 43 (28.1%) 33(21.6%) 26(17%) 51(33.3%)

bathing clients before having sex 154 23(14.9%) 51 (33.1%) 42(27.3%) 38 (24.7%)

taking antibiotics before having sex 153 48 (31.4%) 41 (26.8%) 32 (20.3%) 33 (21.6%)

washing her own vagina after having sex 153 0 4 (2.6%) 19 (12.5%) 129 (84.9%)

having others wash her vagina 151 133 (88.1%) 6 (4%) 7 (4.6%) 5 (3.3%)

3. Bivariate binary logistic regression of self-perceived risk for HIV on

protective actions other than condom use

Protective actions were recoded into dichotomous variables: “never do” coded

as ‘’1” and “do’” coded as ‘2’. They were then examined for their association with self-

perception of risk both independently and altogether through multiple logistic regressions.

Bivariate binary logistic regressions of self-perceived risk for HIV on

protective actions other than condom use were performed. Avoiding sharing needles was

dropped from the analysis as none of the women reported injection drug use. The results are

shown in Table XXXII.

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TABLE XXXII

RESULTS OF BIVARIATE BINARY LOGISTIC REGRESSIONS OF SELF-PERCEIVED RISK FOR HIV SELF-PERCEIIVED RISK FOR HIV (UNLIKELY=81, LIKELY=74, UNLIKELY

AS REFERENCE) ON PROTECTIVE ACTION OTHER THAN CONDOM USE

Independent variable B S.E. p Adjusted OR

95% C.I.for OR

Lower Upper

having shaman inserted traditional implant (susuk)

(never=153, do=2, never as reference) .092 1.423 .949 1.096 .067 17.840

practicing traditional ritual (never=144, do=11, never as reference)

-.099 .628 .875 .906 .264 3.102

bathing herself before having sex (never=45, do=110, never as reference)

.187 .355 .599 1.205 .601 2.419

bathing clients before having sex (never=24, do=131, never as reference)

.496 .456 .278 1.641 .671 4.015

taking antibiotics before having sex (never=50, do=105, never as reference)

.342 .347 .324 1.408 .713 2.777

washing her own vagina after having sex (never=3 do=152 no as reference)

21.150 23205.423 .999 1.533E9 .000 .

having others wash her vagina (never=137, do=18, never as reference)

-.970 .553 .080 .379 .128 1.121

From the table above, only having others wash the women’s vaginas was not removed by

the backward LR. Using the p value’s cut point of 0.1, this protective action was included in

the logistic binary multiple regressions analysis altogether with other statistically significant

intrapersonal characteristics.

E. PART E. Binary Multiple Logistic Regressions Examining the Influence of All

Significant Variables from all 3 Analytic Constructs (Intrapersonal Level,

Perceived Control over Becoming Infected, and Protective Actions Taken) on

Self-perception of Risk for HIV

Binary multiple logistic regressions were performed to examine the influence of all

significant variables from all 3 analytic constructs (intrapersonal level, perceived control over

becoming infected, and protective actions taken) on self-perception of risk for HIV. The

results are shown in Table XXXIII.

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TABLE XXXIII

RESULTS BINARY MULTIPLE LOGISTIC REGRESSIONS EXAMINING THE INFLUENCE OF ALL SIGNIFICANT VARIABLES FROM ALL 3 ANALYTIC CONSTRUCTS

(INTRAPERSONAL LEVEL, PERCEIVED CONTROL OVER BECOMING INFECTED, AND PROTECTIVE ACTIONS TAKEN) ON SELF-PERCEPTION OF RISK FOR HIV

(NUNLIKELY=81, NLIKELY=74, UNLIKELY AS REFERENCE)

Independent variable B S.E. p Adjusted OR

95% C.I.for OR

Lower Upper

Consistent condom use -.861 .407 .035* .423 .190 .939

No (n=81), reference

Yes (n=74)

Self-perception that washing own vagina after having sex controls HIV infection

-.648 .480 .177 .523 .204 1.340

No (n=38), reference

Yes (n=117)

Having others wash her vagina

-1.264 .646 .050 .282 .080 1.001 Never(n= 137, reference

Do (n=18)

Work in bar/discotheque in the last 12 months 1.683 .755 .026* 5.382 1.226 23.629

no (n=138), reference,

Yes (n=17)

Self-perceived risk for diseases: 1.056 .511 .039* 2.874 1.056 7.821

Gonorrhea: unlikely (n= 54), reference

Likely (n=101)

Syphilis: unlikely (n=50), reference 1.929 .550 <.001* 6.882 2.341 20.233

likely (n=105)

DHF: unlikely (n=49), reference .402 .497 .418 1.496 .565 3.958

likely (n=106)

Constant -1.642 .672 .015* .194

* = statistically significant

Table XXXIII reveals that all together consistent condom use, working experience in

bar/discotheque, self-perceived risk for gonorrhea, self-perceived risk for syphilis and Self-

perception that washing own vagina after having sex controls HIV infection affected FSW’s

self-perceived risk for HIV. The increase of consistent condom use lowered the perception,

while the increase of the remaining variables enhanced the self-perceived risk.

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F. PART F: The Model

Results of hypotheses testing showed that four variables affected self-perceived risk

for HIV among female sex workers in the brothel compounds in Surabaya, where periodic

mandatory venereal disease examinations and condom campaign took place for more than

ten years. The model of this study results is describe in Figure 7 below.

Figure 7. The model of factors influencing female sex workers’ self-perceived risk for HIV in Surabaya.

1. Determining mediation and moderation

Did consistent condom use moderate or mediate intrapersonal variables on

self-perceived risk for HIV? The following are the evaluation steps to determine mediation

and moderation of consistent condom use on the effect of intrapersonal variables on self-

perceived risk for HIV.

Intrapersonal Level Variables

Experience of working in bar/discotheque

Self-perceived susceptibility for gonorrhoea

Self-perceived

susceptibility for syphilis

Self-

perceived

Risk for HIV

Protective

Action taken

against HIV

Consistent

condom use with

clients

86

a. The effect of experience of working in bar/discotheque

To determine whether consistent condom use was a moderator or

mediator variable in the model, several examinations were taken.

1. Moderation. To determine a moderation, fitting a model

regressing self-perceived risk for HIV on working experience in bar/discotheque, consistent

condom use, and the interaction term working experience in bar/discotheque * consistent

condom use were conducted. If the interaction had a significant effect, the examination

ended there. This means consistent condom use is a moderator of the effect of working

experience in bar/discotheque on self-perceived risk for HIV. The results are reported in

Table XXXIV.

TABLE XXXIV

RESULTS OF EXAMINATION ON THE MODERATION OF CONSISTENT CONDOM USE OF EXPERIENCE OF WORKING IN BAR/DISCOTHEQUE ON SELF-PERCEIVED RISK

FOR HIV

Independent variable B S.E. p Adjusted

OR

95% C.I.for OR

Lower Upper

Experience of working in bar/discotheque 1.856 1.087 .088 6.400 .760 53.866

Consistent condom use -.985 .355 .006 .373 .186 .749

Experience of working in bar/discotheque by condom

use consistency (interaction)

-.583 1.336 .662 .558 .041 7.651

Table XXXIV shows that there was no interaction effect found

(p=0.662), meaning that consistent condom use was not a moderator of the effect of having

experience of working in bar/discotheque on self-perceived risk for HIV. Because the

87

interaction was not significant, another examination step was taken, which was evaluating

mediation.

2. Mediation. The step began by examining “experience working

as an indirect sex worker in a bar/discotheque” on self-perceived risk for HIV both with and

without adjusting for consistent condom use to determine if self-perceived control over

becoming HIV infected affects consistent condom use.

3.

a). Regression of self-perceived for HV infection on experience of working in

bars/discothequesalone. The results have been shown in Table 3.11 (B=1.412, SE=.597,

p=0.018, unadjusted OR=4.102, CI=1.273 - 13.217).

b) Regression of self-perceived for HV infection on perception that experience of

working in bar/discotheque and consistent condom use. The results are presented in

Table XXXV.

TABLE XXXV

RESULTS OF LOGISTIC BINARY REGRESSION OF SELF-PERCEIVED FOR HV

INFECTION ON EXPERIENCE OF WORKING IN BAR/DISCOTHEQUE ADJUSTING FOR CONSISTENT CONDOM USE

Independent variable B S.E. p Adjusted

OR

95% C.I.for OR

Lower Upper

experience of working in bar/discotheque 1.490 .614 .015* 4.438 1.333 14.782

Consistent condom use -1.030 .341 .003* .357 .183 .697

* = statistically significant

88

c). Comparing the coefficient for the effect of experience of working in

bar/discotheque in the first model (unadjusted) to the coefficient for experience of working in

bar/discotheque in the second model (adjusted for the effect of consistent condom use).

The coefficients were 1.412 (unadjusted) and 1.490 (adjusted). The change was -.078 or -

5.52%. The change in the coefficient was less than 10%.

d) Regression of consistent condom use on perception that washing own vagina

controls HIV infection.

The results are shown in Table XXXVI.

TABLE XXXVI

RESULTS OF BINARY LOGISTIC REGRESSION OF CONSISTENT CONDOM USE ON EXPERIENCE OF WORKING IN BAR/DISCOTHEQUE

Independent variable B S.E. p unadjusted

OR

95% C.I.for OR

Lower Upper

experience of working in bar/discotheque -.031 .515 .952 .970 .353 2.660

Table XXXVI indicates that the effect was not significant. Consistent condom use was

neither a moderator nor mediator affecting the association between the experience of selling

sex while working in a bar/discotheque outside of the Brothel compound and self-perceived

risk for HV infection.

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b. Did consistent condom use moderate or mediate the effect of

self-perceived risk for gonorrhea on self-perceived risk for HIV?

Similar examinations were conducted involving the self-perceived risk

for gonorrhea, consistent condom use and self-perceived risk for HIV.

a) Testing moderation

Table XXXVII shows the results of the evaluaton on moderation of consistent

condom use on the effect of perception that self-perceived risk for gonorrhea on self-

perceived risk for HIV

TABLE XXXVII

RESULTS OF THE EXAMINATION ON MODERATION OF CONSISTENT CONDOM USE ON THE EFFECT OF SELF-PERCEIVED RISK FOR GONORRHEA ON SELF-PERCEIVED

RISK FOR HIV

Independent variable B S.E. p Adjusted

OR

95% C.I.for OR

Lower Upper

Self-perceived risk for gonorrhea 2.007 .558 <.001* 7.437 2.490 22.219

Consistent condom use -.607 .681 .373 .545 .143 2.071

Self-perceived risk for gonorrhea by condom use consistency (interaction) -.404 .802 .614 .667 .139 3.214

* = statistically significant

As the interaction was not significant (p=.614), the procedure continued with the evaluation

of mediation.

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b) Mediation

b.1) Regression of self-perceived for HV infection on self-perceived risk for

gonorrhea alone. The results have been shown in Table 3.9 (B=-1.869, SE=.395, p=<.001,

unadjusted OR=6.481, CI=2.986 - 14.067).

b.2) Regression of self-perceived for HV infection on self-perceived risk for

gonorrhea and consistent condom use. The results are presented in Table XXXVIII.

TABLE XXXVIII

RESULTS OF LOGISTIC BINARY REGRESSION OF SELF-PERCEIVED FOR HV INFECTION ON SELF-PERCEIVED RISK FOR GONORRHEA ADJUSTING FOR

CONSISTENT CONDOM USE

Independent variable B S.E. p Adjusted

OR

95% C.I.for OR

Lower Upper

Self-perceived risk for HIV 1.817 .403 .000 6.154 2.794 13.556

Consistent condom use -.900 .360 .012 .406 .201 .822

b.3) Comparing the coefficient for the effect of self-perceived risk for gonorrhea in the

first model (unadjusted) to the coefficient for the effect of self-perceived risk for gonorrhea

the second model (adjusted for the effect of consistent condom use).

The coefficients were -1.896 (unadjusted) and –(-1.817)(adjusted). The change was

.0052 or 2.74%. There was a change of less than 10% in the coefficient.

b.4) Regression of consistent condom use on self-perceived risk for gonorrhea

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The results of regression of consistent condom use on self-perceived risk for

gonorrhea are shown in Table XXXIX.

TABLE XXXIX

RESULTS OF BINARY LOGISTIC REGRESSION OF CONSISTENT CONDOM USE ON SELF-PERCEIVED RISK FOR GONORRHEA

Independent variable B S.E. p unadjusted

OR

95% C.I.for OR

Lower Upper

Self-perceived risk for gonorrhea -.598 .341 .080 .550 .282 1.073

Table XXXIX shows that the effect was not significant (p=.080). As was also true with HIV,

consistent condom use was neither a moderator nor mediator of the assocaiton between

self-perceived risk for gonorrhea and self-perceived risk for HIV.

c. Did consistent condom use moderate or mediate the effect of

self-perceived risk for syphilis on self-perceived risk for HIV?

Examinations were conducted to determine the moderation of

consistent condom use on the effect os self-perceived risk for syphilis on self-perceived risk

for HIV. The results are reported in Table XL.

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TABLE XL

RESULTS OF THE EXAMINATION ON THE MODERATION OF CONSISTENT CONDOM USE ON THE EFFECT OF SELF-PERCEIVED RISK FOR SYPHILIS ON

SELF-PERCEIVED RISK FOR HIV

Independent variable B S.E. p Adjusted

OR

95% C.I.for OR

Lower Upper

Self-perceived risk for syphilis 4.281 1.072 <.001* 72.308 8.853 590.584

Consistent condom use 1.427 1.137 .209 4.167 .449 38.654

Self-perceived risk for syphilis by condom use consistency (interaction) -2.846 1.216 .019 .058 .005 .630

*= statistically significant

As the interaction was significant (p=.019), the procedure ended.

In contrast to the earlier findings with HIV and Syphilis, consistent condom use was found to

moderate the effect of self-perceived risk for gonorrhea on self-perceived risk for HIV.

2. The final model

Results of hypotheses testing showed that four variables affected self-

perceived risk for HIV among female sex workers in the brothel compounds in Surabaya,

where periodic mandatory venereal disease examinations and condom campaign took place

for more than ten years. Consistent condom use with clients moderated the effect of self-

perceived risk for syphilis on self-perceived risk for HIV. The final model of this study results

is described in Figure 8 below.

93

Intrapersonal Level Variables

Figure 8. The final model of factors influencing female sex workers’ self-perceived risk for HIV in Surabaya.

3. The mathematical model

A mathematical model using the formula of

Logit [P (Y=1)]= β0 + β1(X1)+ β2(X2) + β3(X3) + β4(X4)

that can be built based on the binary multiple logistic regressions results is:

Logit [P(self-perceived risk for HIV)] = -1.642 - .861(consistent condom use) + 1.683 (worked in bar/discotheque) + 1.056 (Self-perceived risk for gonorrhea) + 1.929 (Self-perceived risk for syphilis)

Self-perceived

susceptibility for syphilis

Self-

perceived

Risk for HIV

Protective

Action taken

against HIV

Consistent

condom use with

clients

Experience of working in bar/discotheque

Self-perceived susceptibility for gonorrhoea

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G. Part G: Other Results – Clients’ Power

Although the qualitative data that were collected as part of this study will be

analayzed fully in a separate but complementary study at a later date, FSWs’ answers to

open ended questions regarding condom use suggest that the FSWs often lacked the

personal power to impose condom use among their clients even when they were available.

This power differential in the favour of clients perhaps explains the lack of a statistical

association between the believing that condoms can reduce the risk of HIV and their actual

use. The followings are the quotations that may describe the influence of clients’ power as

FSWs’ interpersonal environment.

Participant P4010

Interviewer: Did that reach half of the clients? Did about half of your total clients use condom? Person 1: No, not really. A quarter, I think. There were clients who were willing to use

condoms and there were clients who were not. But I insisted that they use condoms. Sometimes when I gave them condoms they became suspicious. They asked me, “Why do you ask me to use condom? Are you ill?” In fact, I was the one who was afraid of being infected by the clients. But it was me that they accused of potentially infecting them. So, I said: “Okay, you may skip using condoms if you really don’t have that [HIV, added by author] disease.” So I did not force them [to use condom, added by author].

Participant P5050 Interviewer: What device? Person 1: That device, condoms. Interviewer: Always [use condom, added by author]? Person 1: Sometimes. If the clients did not want to use then they did not use condoms. But I

always asked them to use condoms. If the clients insisted not to use it, well it was okay for the sake of money. Some clients agreed to use condom.

95

IV. DISCUSSIONS

A. Self-perceived Risk for HIV among Women Working in the Brothel Compounds

This cross sectional study examined the influences of intrapersonal characteristics,

perceived control over becoming infected by HIV, and taking protective actions against HIV

on self-perception of risk for HIV among 155 brothel-based FSWs in Surabaya, Indonesia.

The study found increased self-perceived risk for HIV among the women to be associated

with having sold sex in a bar/discotheque outside the brothel in the last 12 months and self-

perceived risk for syphilis and gonorrheal infections. These findings and the results obtained

when examining other key variables that were non-statistically significant in the final set of

analyses are discussed below.

B. The influence of FSWs’ intrapersonal characteristics on self-perceived risk for

HIV infection

The possible association between 8 intrapersonal characteristics and HIV risk

perception were explored, but only three variables were found to be statistically significant as

shown in B1-B8.

1. Age

This study shows that age had a negative association with FSWs’ self-

perceived risk for HIV when examined in using bivariate analysis. The relationship, however,

no longer was statistically significant when evaluated simultaneously with other variables.

2. Education

Level of education was not related to the perception, probably because the

nature of HIV and sex education in Indonesia can be somewhat limited. For example, FSWs’

condom knowledge obtained from school may be minimal because many influential spiritual

96

leaders oppose including information about condom use and HIV within the national school

curriculum. As the consequence, FSWs in the brothels with different levels of education may

be exposed differentially to condom information. While increased level of education was

positively associated with increased risk at the bivariate analysis level, the association was

not sufficiently strong to remain statistically significant when examined in concert with other

variables.

3. Home provinces and hometowns

The results of this study show that urban-rural origins as well as home

province do not affect their perception on HIV risk. This differs from results from other

studies conducted in other countries that indicates risk perception is increased as a result of

the challenges of adapting to a new home environment and difficulties in communicating

regularly with health authorities. The brothel system in Surabaya where this study was

conducted allowed the FSWs to visit their hometowns regularly or at least in the major

religious holidays. Communication with health authorities was maintained through periodic

mandatory STD and HIV screenings.

4. Sex work experience

The past migratory sex work experience also directly affected the HIV risk

perception, particularly being worked in the bar/discotheque as indirect FSWs. Syphilis

prevalence among indirect FSWs (including those working in bar/discotheque) in Indonesian

cities was lower than those among brothel-based FSWs. In Surabaya the prevalence were

1.6 vs 4.5% for active syphilis and 3.2% vs 8.5% for life-time syphilis (Magnani, et al, 2010).

Possibly the women’s exposure to information on syphilis influences their self-perception of

risk for syphilis, which in turn, influences self-perception of risk for HIV.

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5. Alcohol drinking and drug use

This study’s findings do not support the hypothesis that alcohol drinking and

drug use will influence the HIV perception. A study is needed to verify the result on drug use

as the information on drug use was very sensitive.

6. Knowledge

When assessed through the five standardized questions of knowledge on HIV

established by UNAIDS, the women’s average knowledge level was low, suggesting that

they did not fully understand the concept of HIV heterosexual transmission and prevention.

Although it is considered an important factor in explaining an individual’s perception of risk, it

was not statistically significant in this study when examined in concert with other measures.

More specific examination on condom knowledge, which is one of the UNAIDS questions,

revealed that the score of condom knowledge was not associated with the perceived-risk for

HIV.

7. Self-perceived susceptibility to diseases

A positive association was found between self-perceived risk for HIV and self-

perceived-risk for each of two venereal infections: syphilis and gonorrhea. These two

infections are common among brothel-based FSWs in Surabaya. In the 2011, the national

integrated bio-behavioral survey showed the prevalence of chlamydial, gonorrheal and

syphilis infections among FSWs in Surabaya to be 32.4%, 31.2%, and 12.2% respectively.

These statistics echo similar findings reported at the national level for FSWs in general

(MoH, 2012). Meanwhile, during this same time period, HIV prevalence rates among FSWs

in Surabaya was reported at the lower rate of 10.2% in 2007 (Magnani et al, 2010) and

10.4% in 2011 (MoH, 2012).

98

When compared to HIV as a far less common STI among FSWs, personal

exposure to or experiences with syphilis and gonorrhea likely made these diseases more

visible and the risk of acquiring them more tangible to FSWs than AIDS or HIV infection.

Also, monthly STI screening and treatment of the two venereal diseases if indicated -- which

was mutually agreed upon as a local public health program by brothel managers, a special

task force on HIV prevention, and the STI clinics -- likely exposed the study’s participants to

more information about these two venereal diseases than to HIV. In the absence of a full

comprehension about HIV as a disease and how it is transmitted (as indicated by the lack of

an association between HIV knowledge and perceived HIV risk among study participants as

reported above), experience with and perceived risk for gonorrhea and syphilis became the

heuristic tool with which the FSWs calculated their risk for HIV. This premise is consistent

with results from the 2007 IBBS sero-survey showing that higher likelihoods of HIV infection

were positively associated with testing positive for gonorrhea and/or chlamydia (OR=1.35)

and syphilis (OR=1.61) (Magnani et al, 2010). The FSWs in this study may not be aware of

these 2007 IBBS findings, but they might conclude from the experience of other FSWs

tested positive for HIV who in the past have tested positive for syphilis or gonorrhea. The

information on HIV test results was kept confidential, however, the reactions from those who

found that they were affected, the absence of the affected one for regular visits to the referral

centers for HIV treatment, may act as clues for others. The laboratory examination results of

syphilis and gonorrheal infections were also kept confidential by the local public health

centers, however, the work leaves that FSWs took when they were contracted the diseases

might provide clues to their peers.

The associations between the risks for both venereal diseases and HIV were

also likely to be built through an analogy of (1) the shared route of infections, although FSWs

were also aware that HIV infection could be spread through injection needle sharing; (2) the

similar prevention efforts, which were consistent condom use; (3) the way of knowing

99

whether they were affected by the 3 infections was also similar, which was getting screened

in the STD clinics where VCT clinics were integrated, although the screening intervals were

different. Indeed, scientific findings agree on the role of vaginal mucosal disruptions in

facilitating HIV invasion such as in an ulcerative syphilis and later on become co-infections

(Fleming & Wasserheit, 1999; Nusbaum, Wallace, Slatt & Kondrad, 2004) – a point that the

FSWs might be unaware of but can benefit the HIV prevention program.

This study found that the more FSWs who perceived that they could control

becoming infected by washing their vagina after having sex were less likely to perceive

themselves at risk for HIV. There was no evidence of a significant association between

intrapersonal characteristics and consistent condom use. The latter, however, is associated

with level of education in bivariate analysis, although the association diminishes to

nonstatistical significance when itested simultaneously with other variables. The lower a

woman’s level of education, the more likely she is to believe that washing her vagina

controls HIV infection (OR =.321, p=0.004, not shown in Chapter 3). This might be

associated with general knowledge on personal hygiene.

8. Perceived susceptibility of peers

This study shows that perceived susceptibility of peers positively affected the

FSWs’ self-perceived risk for HIV in the bivariate regressions analysis, however, the

association diminished to non-statistical significance when assessed simultaneously with

other variables.

100

C. Perceived Controls over Becoming Infected by HIV and Self-perceived Risk for

HIV Infection

Study findings did not support the hypothesis that perceived controls over becoming

infected by HIV influences self-perceived risk for HIV. While FSWs’ belief that washing their

own vagina could control the acquisition of HIV, the relationship was reduced to non-

statistical significance when using multiple logistic regression.

D. Protective Actions Against HIV and Self-perceived Risk for HIV Infection

Traditional practices that Indonesian FSWs undertake to protect themselves against

disease including HIV were not associated with their perception of HIV risk. Only condom

use as a protective strategy was shown to influence their perception.

The increase in consistent condom use with clients in the past 7 days decreased the

self-perceived risk for HIV. Contrary to results reported by other studies on sex workers,

condom usages with local, Indonesian foreigner and non-Indonesian foreigner clients were

not associated with perception of HIV risk. This finding suggests that the xenophobia found

among FSWs elsewhere that equates foreigner clients as being more likely to pose HIV risk

than local clients was not present in the Surabaya brothels where this research was

conducted.

E. Limitations of the Study

The sample from this study was collected through convenience sampling. The

external validity of the research would be improved through random sampling. Also, the

study is cross-sectional, thus the direction of association remains unclear. The sample size

was relatively small that underpower might occurr. People’s perception of risk may change

over time, a process and outcome that this study is unable to capture. In addition, HIV and

101

the behavior with which it is associated are sensitive topics. Consequently, the danger

exists as with all HIV studies that the FSWs may not always have been completely truthful.

Finally, although a thoughtful attempt was made to sample brothels typical to the compound

area, the experiences of the women employed at the recruitment sites may not represent

those of women working in all Surabaya brothel establishments.

F. Conclusion and Future Research Direction

Unlike FSWs who practice commercial sex in social environments where little

information about HIV is available, FSWs working in Surabayan brothels are required by the

local law to have regular clinical check-ups that include counseling sessions about how to

avoid STIs. That the women who participated in this study have such a low level of

understanding about HIV, its transmission, and how to protect themselves against acquiring

it is troubling. This finding calls for more effective educational programming and efforts both

through clinics and other means to better educate this vulnerable population about the

dangers of HIV and how to protect themselves.

The Indonesian national surveys on HIV used binary measurements, omitting

‘somewhat likely’ as one of the options. This study used three option responses of self-

perceived risk and later on converted them to a binary scale, merging the ‘somewhat likely’

option to ‘likely’. By using this strategy, this study was capable of finding a 6.7% difference

(61.6% in the 2011 survey and 68.3% in this study). The 6.7% might be of those who were

reluctant to admit as at risk in the 2007 and 2011 national surveys. The use of three-option

answers may be useful in the future with a bigger sample size.

102

Further research to test the fitness of this study’s model is needed, involving

consistent condom use, self-perceptions on risks for gonorrhea and syphilis, and sex work

experience. Sex work experience may be examined at the higher level of the social-

ecological model such as organizational environment. Studies that include the higher levels

of social ecological model and assessment on risk for venereal diseases also are needed to

better explain the range of influences on HIV risk self-assessment. This would involve the

clients’ perception on condom use at the interpersonal level of environment.

103

APPENDICES

104 APPENDIX A: IRB APPOVAL DOCUMENTS

105 APPENDIX A: IRB APPOVAL DOCUMENTS (continued)

106 APPENDIX A: IRB APPOVAL DOCUMENTS (continued)

107 APPENDIX A: IRB APPOVAL DOCUMENTS (continued)

108 APPENDIX A: IRB APPOVAL DOCUMENTS (continued)

109

APPENIX B: QUESTIONNAIRE

“FACTORS INFLUENCING BROTHEL-BASED FEMALE SEX WORKERS’ SELF-PERCEIVED RISK FOR HIV IN SURABAYA, INDONESIA”

Principal investigator: Samsriyaningsih Handayani The School of Public Health

University of Illinois at Chicago Note: Parts of this questionnaire are adapted from the IBBS 2007 questionnaire (MOH, 2007) and a questionnaire on stigma perception among female sex workers in Chennai, India ( Liu, Srikrishnan, Zelaya, Solomon, Celentano & Sherman, 2012) CONFIDENTIAL PLACE IDENTIFICATION Respondent no. Name of Interviewer ___ Date of Interview Date Month Yr Inteview start time ___________ The answers to this questionnaire have been examined for completeness and consistency: Principal Investigator:

110

APPENDIX B: QUESTIONNAIRE (continued)

INTRODUCTION 1. Greetings (for example: Good Morning/Good Afternoon/Good Evening). 2. Introduce yourself. 3. Explain the intention and goal of the research 4. Emphasize the confidentiality of the responses, and let the person know that the

name of the respondent will not be recorded. 5. Ask about the person’s willingness to be a respondent and to answer the

questions honestly. 6. Thank the person for her willingness to serve as a respondent. 7. Ask the participant to hand over her participant code that the principal

investigator gave her. Do not ask the participant to mention her real name.

THE INTERVIEWER SETS UP A PRIVATE ATMOSPHERE IN WHICH TO CONDUCT THE INTERVIEW. MAKE SURE NO ONE ELSE IS THERE WHILE THE INTERVIEW IS TAKING PLACE.

[INTERVIEWER: TURN ON THE TAPE RECORDER] (INTERVIEWER READ: ) My interviewer code is: (code) The participant code is: (code) Can we begin the interview? [INTERVIEWER: TURN OFF THE TAPE RECORDER. CHECK WHETHER THE TAPING IS SATISFYING. IF NOT, REPEAT THE TAPING UNTIL YOU GET A CLEAR RECORD, THEN GO ON WITH THE INTERVIEW]

111

APPENDIX B: QUESTIONNAIRE (continued)

A. DEMOGRAPHIC CHARACTERISTICS

INTERVIEWER: I would like to begin this interview by asking you about your age, ethnic group, educational status and marriage status.

Question Answer

Code (filled by PI)

A1 How old are you? Age: .................... years A1

A2 Which ethnic group do you

feel you belong to?

1. Javanese

2. Madurese

3. Sundanese

4. Balinese

5. Other ______________

A2

A3 Highest level of education you

have attended?

1. Never been to school

2. Elementary school/equivalent

3. Junior High/equivalent

4. Senior High/equivalent

5. College/University

9. No answer

A3

A4 What is your current marital

status?

[Read aloud the answer

choices]

1. Never married

2. living together

3. Married not living together

4. Divorced

5. Widow

9. No answer

A4

112

APPENDIX B: QUESTIONNAIRE (continued)

B. MIGRATION HISTORY INTERVIEWER: Now I would like to ask you a little about your migration history. Let’s start with where you came from.

Question Answer Code (filled by PI)

B1 When you go home, where do

you go? By “home,” I mean the

place where your husband and

children live if married or place

where your parents live if not

married.

a. District/City**):

...............................................

b. Province:

...............................................

B1a

B1b

B2 How long ago did you first

exchange sex for

money? Please tell me the

month and year.

a. Month: __ __

b. Year: __ __ __ __ [Month:

01 = January 07= July

02 = February 08 = Aug.

03 = March 09= Sept.

04 = April 10 = Oct.

05 = May 11 = Nov.

06 = June 12= Dec.

98 Don’t remember

99 No answer]

Year: 19_ _

9998 Don’t remember

9999 Decline to answer]

B2a

B2b

B3 In how many different brothel

establishments have you

worked in the twelve months?

01 [or more]

88. Don’t remember

99. No response

B3

113

APPENDIX B: QUESTIONNAIRE (continued)

Question Answer

Code (filled by PI)

B4

How long have you been having

sex in exchange for money in

this city? Please tell me how

many months and years.

a. Months: __ __

b. Years: __ __

01 [or more]

98 Does not remember

99 Decline to answer

B4a

B4b

INTERVIEWER: In the past 12 months, in which of the following establishment / place have you contacted clients? Have you contacted a client in a:

B5

No Yes Don’t

remember/

Don’t

know

Decline

to

answer

Code (filled

by PI)

A. Karaoke bar 1 2 8 9 B5A

B. Massage parlor 1 2 8 9 B5B

C. Bar / discotheque 1 2 8 9 B5C

D. Restaurant / food stalls 1 2 8 9 B5D

E. Street 1 2 8 9 B5E

F. Brothel localization 1 2 8 9 B5F

G. Other, specify:

...........................................

B5G

114

APPENDIX B: QUESTIONNAIRE (continued)

Question Answer Code (filled

by PI)

B6. Have you ever exchanged

sex for money in another

city?

No 1 skip to Q8

Yes 2

DK 8 skip to Q8

DA 9 skip to Q8

B6

B7. Prior to this city, in which

cities/ provinces/countries

did you have sex in

exchange for money in the

past 12 months?

District/City/Province/Country

a. none, I did not have sex in

another city in the past 12 months

b______________

c______________

d_______________

B7a

B7b

B7c

B7d

[INTERVIEWER: TURN ON THE TAPE RECORDER. TAKE

NOTES. RECORD ON TAPE: MIGRATION HISTORY, B8]

B8. During Ramadhan in 2011, what did you do for a living? Did you engage in sex for

money? [If yes:]

Was that in a boarding house?

Hotel?

Your client’s place?

B9. Did you work or earn money in other ways that did not involve exchanging sex for

money? [If yes:]

How did you earn money?

[INTERVIEWER: TURN OFF TAPE RECORDER]

115

APPENDIX B: QUESTIONNAIRE (continued)

C. HIV AWARENESS AND SELF-PERCEIVED RISK No Yes Don’t

Know Decline

to answer

Code (filled by PI)

C1 Have you ever heard about HIV?

1 Skip to Section L on pg. 23

2 8 9 C1

C2 Have you ever been to an STD clinic for a regular check-up?

1 2 8 9 C2

C3 Have you ever visited the STI mobile van?

1 2 8 9 C3

[Interviewer instructions for next set of questions: Ask all 3 questions in boxes a-c about Dengue fever before going on to ask all 3 questions about gonorrhea and each of the other disesease. Do not read DK (don’t know) or DA (decline to answer) outloud.] INTERVIEWER: Now I would like to ask you your thoughts about several health conditions.

a. Do you ever worry about getting ___?

Would you say:

b. How serious is _________? Would you say:

c. How likely are you to get _________ in the next 12 months? Would you say that you are:

d. How embarrassed will you feel if, at all, other people know about you getting _____?

Code (filled by PI)

C4. Dengue Hemorrhagic fever?

Would you say…

1. Never 2. Sometimes 3. Frequently 4. Always 8. Dk 9. DA

1. Not serious 2. Somewhat

serious 3. Very

serious 8. DK 9. DA

1. Unlikely 2. Somewhat

likely 3. Very likely 8. DK 9. DA

1. Not at all 2. Somewhat

embarrassed 3. Very

embarrassed 8. DK 9. DA

C4a

C4b

C4c

C4d

116

APPENDIX B: QUESTIONNAIRE (continued)

a. Do you ever worry about getting ___?

Would you say:

b. How serious is _________? Would you say:

c. How likely are you to get _________ in the next 12 months? Would you say that you are:

d. How embarrassed will you feel if, at all, other people know about you getting _____?

Code (filled by PI)

C5. Gonorrhea? Would you

say…

1. Never 2. Sometimes 3. Frequently 4. Always 8. Dk 9. DA

1. Not serious 2. Somewhat

serious 3. Very

Serious 8. DK 9. DA

1. Unlikely 2. Somewhat

likely 3. Very likely 8. DK 9. DA

1. Not at all 2. Somewhat

embarrassed 3. Very

embarrassed 8. DK 9. DA

C5a

C5b

C5c

C5d

C6. Syphilis? Would you

say…

1. Never 2. Sometimes 3. Frequently 4. Always 8. Dk 9. DA

1. Not serious 2. Somewhat

serious 3. Very 4. serious 8. DK 9. DA

1. Unlikely 2. Somewhat

likely 3. Very likely 8. DK 9. DA

1. Not at all 2. Somewhat

embarrassed 3. Very

embarrassed 8. DK 9. DA

C6a

C6b

C6c

C6d

C7. Common cold? Would you say…

1. Never 2. Sometimes 3. Frequently 4. Always 8. Dk 9. DA

1. Not serious 2. Somewhat

Serious 3. Very serious

8. DK 9. DA

1. Unlikely 2. Somewhat

likely 3. Very likely 8. DK 9. DA

1. Not at all 2. Somewhat

embarrassed 3. Very

embarrassed 8. DK 9. DA

C7a

C7b

C7c

C7d

C8. HIV? Would you say…

1. Never 2. Sometimes 3. Frequently 4. Always 8. Dk 9. DA

1. Not serious 2. Somewhat

Serious 3. Very serious

8. DK 9. DA

1. Unlikely 2. Somewhat

likely 3. Very likely 8. DK 9. DA

1. Not at all 2. Somewhat

embarrassed 3. Very

embarrassed 8. DK 9. DA

C8a

C8b

C8c

C8d

117

APPENDIX B: QUESTIONNAIRE (continued)

INTERVIEWER: TURN ON TAPE RECORDER AND TAKE NOTES C9a. How likely is it that another sex worker whom you work in the same brothel with

will get HIV?

1. Unlikely 2. Somewhat likely C9a 3. Very likely

b. Why do you think this? (Probe: Can you tell me more)

___________________________________

C10a. Do you ever worry about someone whom you love getting HIV?

1. Never skip to Section D 2. Sometimes 3. Frequently C10a 4. Always

8. Don’t know 9. Declline to answer

b. Why do you feel this way? (Probe: Can you tell me more)

___________________________________

[INTERVIEWER: TURN OFF TAPE RECORDER]

118

APPENDIX B: QUESTIONNAIRE (continued)

D. PERCEIVED CONTROL AND PROTECTIVE ACTION

[Interviewer instructions for next set of questions: Ask both questions in boxes a and b for E1 before , then E1b bfore asking E2a and E2b and so on. Do not read DK (don’t know/can’t remember) or DA (decline to answer) out loud]

Interviewer: Now I would like to ask you a few questions about what, if anything, can be done to protect yourself from getting HIV.

a. Can you protect yourself from HIV if you.....

b. In the last 30 days, how often did you ….

Code (filled by PI)

D1 Use condoms with new clients

1. No 2. Yes 8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D1a

D1b

D2 Avoid sharing injection needles

1. No 2. Yes 8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D2a

D2b

D3 Have a shaman insert a traditional implant for ahealthy life (susuk kesehatan)

1. No 2. Yes 8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D3a

D3b

D4 Practice traditional rituals 1. No

2. Yes 8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK/DR 9. DA

D4a

D4b

119

APPENDIX B: QUESTIONNAIRE (continued)

a. Can you protect yourself from HIV if you.....

b. In the last 30 days, how often did you ….

Code (filled by PI)

D5 Bathe yourself before having sex 1. No

2. Yes

8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D5a

D5b

D6 Bathe your clients before having sex

1. No 2. Yes 8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK/DR 9. DA

D6a

D6b

D7 Take antibiotics before having sex

1. No 2. Yes 8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D7a

D7b

D8 Wash your vagina after having sex

1. No 2. Yes

8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D8a

D3b

D9 Have others wash your vagina periodically

1. No 2. Yes

8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D9a

D9b

120

APPENDIX B: QUESTIONNAIRE (continued)

[INTERVIEWER: TURN ON TAPE RECORDER AND TAKE NOTES]

D12a Are there religious practices or activites that can protect you against HIV?

1. No skip to D17a. 2. Yes 8. Don’t know skip to D17a. D12a 9. Decline to answer skip to D17a.

b. What religious practices or activities protect against HIV?

________________

c. In the last 30 days, which religious practices or activities did you do (if any) to

protect yourself against HIV? _________________

a. Can you protect yourself from HIV if you.....

b. In the last 30 days, how often did you ….

Code (filled by PI)

D10 Ask your client about his HIV status?

1. No 2. Yes 8. DK 9. DA

1. Never 2. Sometimes 3. Frequently 4. Always 8. DK 9. DA

D10a

D10b

D11 Other (please specify)

[INTERVIEWER: TAKE NOTES]

121

APPENDIX B: QUESTIONNAIRE (continued)

D13a. Are there herbs that can protect you against HIV?

1. No skip to Section F 2. Yes D12a

8. Don’t know skip to Section F 9. Decline to answer skip to Section F

b. What herbs protect against HIV? _________________________

c. In the last 30 days, did you use herbs to protect yourself against HIV?

1. Yes 2. No 8. Don’t know D12c 9. Decline to answer

If yes, what did you use? ______________________________

E. PERCEIVED KNOWLEDGE OF HIV

INTERVIEWER: Now I would like to ask you a few questions about what you know about HIV. E1. How much do you know about HIV? Would you say that you know:

1. Nothing 2. A little 3. More than a little 4. A lot E1

8. Don’t know 9. Decline to answer E2. Please describe what you think HIV infection is. E3. How is it transmitted? E4. Who is likely to get HIV? Probe: Do women who engage in sex work get HIV? If yes, how? If no, why not?

[INTERVIEWER: TURN OFF TAPE RECORDER]

122

APPENDIX B: QUESTIONNAIRE (continued)

F. LEVEL OF HIV KNOWLEDGE (ADOPTED FROM UNITED NATION GENERAL

ASSEMBLY SPECIAL SESSION ON HIV/AIDS)

INTERVIEWER: Now I would like to ask you a few questions more questions about HIV and how it is transmitted or avoided.

No Yes Don’t know

Decline to answer

Code (filled by PI)

F1. Can having sex with only one faithful uninfected partner reduce the risk of HIV transmission?

1 2 8 9 F1

F2. Can using condoms reduce the risk of HIV transmission?

1 2 8 9 F2

F3. Can a healthy-looking person have HIV? 1 2 8 9 F3

F4. Can a person get HIV from mosquito bites?

1 2 8 9 F4

F5. Can a person get HIV by sharing a meal with someone who is infected?

1 2 8 9 F5

F6. Can people infected with HIV receive a medical treatment that would enable them to live healthy for a longer period of time?

1 2 8 9 F6

123

APPENDIX B: QUESTIONNAIRE (continued)

G. PEER’S SUPPORT INTERVIEWER: Now I would like to know about other women who work as you do in this brothel. In the last 30 days, how often did

one or more of the women with whom you work …

Answer Code (filled by PI)

G1 Discuss HIV prevention with you? 1. Never 2. Sometimes 3. Frequently 8. Don’t know 9. Decline to answer

G1

G2 Advise you to offer condoms to your clients?

1. Never 2. Sometimes 3. Frequently 8. Don’t know 9. Decline to answer

G3

G3 Remind or advise you to go every 3 months for a HIV/STI check-up?

1. Never 2. Sometimes 3. Frequently 8. Don’t know 9. Decline to answer

G4

G4 Advise you NOT to drink alcohol? 1. Never 2. Sometimes 3. Frequently 8. Don’t know

9. Decline to answer

G5

G5 Advise you NOT to use drugs? 1. Never 2. Sometimes 3. Frequently 8. Don’t know . 9. Decline to answer

G6

G6 Advise you NOT to inject narcotics? 1. Never 2. Sometimes 3. Frequently 8. Don’t know 9. Decline to answer

G7

124

APPENDIX B: QUESTIONNAIRE (continued)

H. PERCEPTION OF BROTHEL MANAGER’S SUPPORT

INTERVIEWER: Now I would like to ask you some questions about your brothel manager.

In the last 30 days, how often did your manager…..

Code (filled by PI)

H1.

Discuss HIV prevention with you? 1. Never 2. Sometimes 3. Frequently 8. Don’t know 9. Decline to answer

H2

H2.

Advise you to offer condoms to your clients?

1. Never 2. Sometimes 3. Frequently 8. Don’t know 9. Decline to answer

H2

H3.

Provide you with free condoms? 1. Never 2. Sometimes 3. Always 8. Don’t know 9. Decline to answer

H3

H4 Remind or ask you to go for 3-month STI/HIV checkups?

1. Never 2. Sometimes 3. Always 8. Don’t know 9. Decline to answer

H4

H5 Advise you NOT to drink alcohol? 1. Never 2. Sometimes 3. Always 8. Don’t know 9. Decline to answer

H5

H6 Advise you not to use drugs? 1. Never 2. Sometimes 3. Always 8. Don’t know 9. Decline to answer

H6

H7 Advise you NOT to inject narcotics? 1. Never 2. Sometimes 3. Always 8. Don’t know 9. Decline to answer

H7

125

APPENDIX B: QUESTIONNAIRE (continued)

I. PERCEPTION ON NON GOVERNMENTAL ORGANIZATION’S (NGO’S) SUPPORT INTERVIEWER: The questions that I would like to ask you now are about the non-governmental organizations that works on HIV prevention in this localization

Question Answer Code (filled by PI)

I1 In the last 3 months, how many times have you been contacted by an NGO fieldworker to discuss about HIV/STI transmission and prevention?

1. Never 2. Once 3. 2-3 times 4. 4 times or more 8. Don’t know 9. Decline to answer

I1

I2 When did you last participate in face-to-face individual discussion to assess your risk of getting infected with HIV and give you options to avoid it?

1. Never participated to such discussion

2. In the past 3 months 3. Between 4 months and a

year ago 4. More than a one year ago 8. Don’t know 9 Decline to answer

I2

I3 In the last 3 months, did you receive any printed material (e.g booklet, brochures, calendar) providing information about HIV transmission and prevention?

1. No 2. No 8. Don’t know 9. Decline to answer

I3

I4 In the last 3 months, when you had questions regarding HIV, did a NGO help you with the answer?

1. No 2. Yes 3. Not applicable, I didn’t have

any questions 8. Don’t know 9. Decline to answer

I4

I5 In the past three months, when you have issues with condoms, did NGO help you with the solution?

1. No 2. Yes 3. Not applicable, I didn’t have

any questions 8. Don’t know 9. Decline to answer

I5

126

APPENDIX B: QUESTIONNAIRE (continued)

INTERVIEWER: TURN ON THE TAPE RECORDER, SAY J6a TAKE NOTES] I6a. Thinking back to the last time that you visited an NGO, do you feel that the

NGO counselor with whom you met was helpful to you in finding ways to avoid HIV? Would you say:

1. Not at all helpful 2. Somewhat helpful I6a 3. Very helpful

b. Why do you feel this way? (Can you tell me more?)

c. Was the language that was used understandable? (Can you tell me more?) Probe: If not, why not? d. Was media shown and if so, was it helpful? (Can you tell me more? What media was that?)

Probe: If not, why not? e. Were you shown how to use a condom?

Probe: Do you think that you know how to use one now? Why or why not? f.. Were you shown how to prevent a condom from breaking?

Probe: Do you think you know how to keep one from breaking? Why or why not?

INTERVIEWER: TURN OFF TAPE RECORDER J. PERCEPTION OF STI/HIV VCT FACILITIES INTERVIEWER: Now let us talk about your experience with sexually transmitted infection clinics, and HIV voluntary counseling and testing facilities]

Question Answer Code (filled by PI)

J1 In the past three months, how many times have you visited an STI clinic for a health and STI checkup?

1. Never 2. Once 3. 2-3 times 4. 4 or more times 8. Don’t know 9. Decline to answer

J1

127

APPENDIX B: QUESTIONNAIRE (continued)

Question Answer

Code (filled by PI)

J2. Last time you went for STI check-up, who suggested you to go?

1. Myself 2. Friend / outreach worker 3. Brothel management 4. The local community

special task force on HIV/AIDS

5. The government 6. Other..........................

J2

J3. Do you know where in this city, people can go to get a confidential test to find out if one has been infected with HIV? By confidential I mean that no one else will know the results of your test unless you want them to know.

1. No 2. Yes

8. Don’t know 9. Decline to answer

J3

J4. Have you ever been tested for HIV?

1. No skip to section L 2. Yes 8. Don’t know skip to section L 9. Decline to answer skip to section L

J4

J5. What do you think of the helpfulness of the pre-test counseling content for your understanding on HIV?

1. Not helpful 2. Somewhat helpful ful 3. Very helpful 8. Don’t know/ don’t

remember 9. Decline to answer

J5

J6. What do you think of the helpfulness of the post-test counseling content for your understanding on HIV?

1. Not helpful 2. Somehwhat helpful ful 3. Very helpful 8. Don’t know/ don’t

remember 9. Don’t answer

J6

J7. What do you think of the helpfulnees of the counselor services regarding your understanding on HIV?

1. Not helpful 2. Somewhat helpful 3. Very helpful 8. Don’t know/ don’t

remember 9. Don’t answer

J7

128

APPENDIX B: QUESTIONNAIRE (continued)

Question

Answer Code (filled by PI)

J8. What do you think of the helpfulnees of other clinic staff members’ service regarding your understanding on HIV?

1. Not helpful 2. Somewhat helpful 3. Very helpful 8. Don’t know 9. Decline to answer

J8

J9. What do you think of the helpfulness of the HIV prevention materials in the clinic for understanding HIV? [HIV prevention materials include flyers, booklets, posters, artificial penis, condoms]

1. Not helpful 2. Somewhat helpful 3. Very helpful 8. Don’t know 9. Decline to answer

J9

J10. What do you think of laboratory workers regarding your understanding on HIV testing?

1. Not helpful 2. Somewhat helpful 3. Very helpful 8. Don’t know 9. Decline to answer

J10

J11. The Last time you got tested, did you receive the result of the test you took?

1. No 2. Yes 8. Don’t know 9. Decline to answer

J11

J12.

Do you know where to get the medication for HIV in your city?

1. No 2. Yes 8. Don’t know 9. Decline to answer

J12

J13. Do you think that you could receive these medication if you would need it?

1. No 2. Yes 8. Don’t know 9. Decline to answer

J13

129

APPENDIX B: QUESTIONNAIRE (continued)

[INTERVIEWER: TURN ON THE TAPE RECORDER. SAY: STI/HIV FACILITIES. TAKE NOTES]

J15. Were you satisfied with the services that you received at the clinic. Would you say that you were:

1. Not at all satisfied? 2. Somewhat satisfied? 3. Very satisfied? 8. Don’t know 9. Decline to answer

b. Why do you feel this way?

INTERVIEWER: TURN OFF TAPE RECORDER. K. SOURCE OF INFORMATION INTERVIEWER: Now I would like to know about how you learned about HIV. Please tell me allthe sources of information.

No

Yes

Don’t know

Decline to answer

Code (filled by PI)

K1 Radio 1 2 8 9 K1

K2 TV 1 2 8 9 K2

K3 Newspaper/magazine 1 2 8 9 K3

K4 A Poster 1 2 8 9 K4

K5 Health worker 1 2 8 9 K5

K6 Outreach worker 1 2 8 9 K6

K7 Peer educator 1 2 8 9 K7

130

APPENDIX B: QUESTIONNAIRE (continued)

L. PERCEPTION ON STIGMA (adapted from Liu, Srikrishnan, Zelaya, Solomon,

Celentano & Sherman, 2012) INTERVIEWER: Now I would like to ask you about how you feel about revealing your job to others No Yes Don’t

know Decline to answer

Code (filled by PI)

L1 Do you feel that if you disclosed being a sex worker to some people they would not talk to you anymore?

1 2 8 9 L1

L2 Do you feel that if you disclosed being a sex worker to some people they would not talk to your family?

1 2 8 9 L2

L3 Do you feel that if you disclosed being a sex worker to some people would think you were immoral?

1. 2 8 9 L3

L4 Do you feel that if you disclosed being a sex worker to some people, you would be threatened with violence?

1. 2 8 9 L4

L5 Do you feel that if you disclosed being a sex worker to some people, they would treat you differently

1. 2 8 9 L5

No

Yes

Don’t know

Decline to answer

Code (filled by PI)

K8 Counsellor 1 2 8 9 K8

K9 Internet 1 2 8 9 K9

K10 Other co-workers (female

sex workers)

1 2 8 9 K10

K11 Other

………………..

K11

131

APPENDIX B: QUESTIONNAIRE (continued)

M. SEX WORK EXPERIENCE INTERVIEWER: Now I would like to ask you a few questions about your experience of engaging in sex for money in the establishment where you work now.

M1. How long have you workied in this place? Please tell me in number of years and

months? [Interviewer, use 00 for no years or months]

a. years __ __ b. months __ __

88. Don’t know M1 99. Decline to answer

M2. a. In the past 7 days, how many men did you sexually serve?

__ ___

88. Don’t know skip to QM6 99. Decline to answer skip to QM6 M2a

b. With how many of these ___ men did you use condoms?

__ __ __

88. Don’t remember M2b 99. Decline to answer

[Interviewer instructions: First ask questions in boxes “a” and “b” about C3 (local residents), then both questions in boxes “a” and “b” about C4 (Indonesian outsiders), and so on. Insert the number of men in question “a” below that were reported in C2.

a. Of the ___ men that you served in the past 7 days, how many were:

b. With how many did you use condoms?

Code (filled by PI)

M3 local residents __ __ 88 Don’t know 99 Decline to answer

__ __ 88 Don’t know 99 Decline to answer

M3

132

APPENDIX B: QUESTIONNAIRE (continued)

a. Of the ___ men that you served in the past 7 days, how many were:

b. With how many did you use condoms?

Code (filled by PI)

M4 Indonesian outsiders (Indonesian nationalities whom the participant considers as not indigenous)

__ __ 88 Don’t know 99 Decline to answer

__ __ 88 Don’t know 99 Decline to answer M4

M5 Foreign outsiders (non-Indonesian nationalities)

__ __ 88 Don’t know 99 Decline to answer

__ __ 88 Don’t know 99 Decline to answer

M5

M6. In the last 3 months, have you ever been forced to do sex against your will? Would you

say…? 1. never 2. sometimes 3. frequently M6 4. always/every time you had sex 8. Don’t know 9. Decline to answer

N. DRUG AND ALCOHOL USE Interviewer: I would like to ask sensitive questions about alcohol drinking and drug use. This information will be kept confidential just as otherinformation that we have discussed will also be kept confidential. Please answer these questions as honestly as possible.

N1. In the past 3 months, how often did you have a drink that contains alchohol (arak, palm wine, beer, whiskey, etc.) before having sex? Would you say:

1. Never 2. A few times 3. Frequently 4. Don’t know N1 5. Decline to answer

133

APPENDIX B: QUESTIONNAIRE (continued)

N2. In the past 3 months, did you use exstasy, amphetamine or ice before having sex? Would you say:

1. Never 2. A few times 3. Frequently N2 8. Don’t know 9. Decline to answer

N3. In the past 3 months, have you injected narcotics? Would you say:

1. Never 2. A few times 3. Frequently N3 8. Don’t know 9. Decline to answer

O. FUTURE PLANS

O1. I heard that the government would close some localizations. If that happens,

what occupation do you plan to have for in the future?

O2. Where?

Interviewer: Before ending the interview, Carefully review the questionnaire/respondent’s answers for completeness

INTERVIEWER: Thank you for your participation

INTERVIEWER NOTES

134

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CURRICULUM VITAE

Samsriyaningsih Handayani, dr., M. Kes., M.Ed Department of Public Health and Preventive Medicine, Airlangga University

Jl. Prof. Moestopo 47 Surabaya Phone: 031-5014067

EDUCATION 2009 - 2013 PhD Candidate, Health Policy and Administration, School of Public Health,

University of Illinois at Chicago, USA, scholarship provided by the United States Agency for International Development (USAID)

2007 – 2008 Master of Education (M.Ed) - Leadership, Policy and Change, Monash

University, Australia, fellowship granted by the World Bank and the Ministry of National Education of the Republic of Indonesia

1996 – 1999 Magister Kesehatan (M.Kes) (Master of Health) - Health Administration and

Policy, Airlangga University, Indonesia, fellowship granted by the Ministry of National Education of the Republic of Indonesia

1983 – 1990 Medical Doctorate- School of Medicine, Airlangga University, Indonesia WORK EXPERIENCE 2006 – 2008: Academic staff at Medical Education, Research and Staff Development Unit,

School of Medicine, Airlangga University, Surabaya, Indonesia o Involved in the design and evaluation of the medical student

curriculum o Assisted in the school’s preparation for international accreditation o Conducted research relating to quality assurance of the medical

curriculum, curriculum relevance with users’ needs (community, hospitals, private clinics) and graduate employability

1994 – 2008: Academic staff at the Department of Public Health and Preventive Medicine,

School of Medicine, Airlangga University, Surabaya, Indonesia o Prepared and delivered lectures on ‘Health Policy and Administration’

and ‘Introduction to Critical Appraisal for Undergraduate Medical Students’

o Prepared, coordinated and supervised medical students’ residency and fieldwork, including collaborating with East Java health authorities and government research centres

o Conducted research in public health area 1992 – 1995: Medical doctor and manager of Primary Public Health Center of Curahdami,

Bondowoso, East Java, Indonesia o Conducted promotion, preventive, curative and rehabilitative activities

to enhance the health status of rural communities

PUBLICATIONS Handayani, Samsriyaningsih. Deliveries attended by health personnel in Bondowoso,

“Majalah Kesehatan Masyarakat Indonesia” (Journal of the Indonesian Public Health Association), July, (7), (1998).

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Handayani Samsriyaningsih., “Percobaan bunuh diri di kalangan remaja di Surabaya – studi di Rumah Sakit Dr. Soetomo Surabaya” (Suicide attempts among adolescents - a case series in Dr. Soetomo General Hospital Surabaya), Medika, May, (1998).

PROJECT REPORTS Sujono, Harjono; Rahardjo, Pudjo; Sunarjo; Kuntoro. Contributors: Umiastuti, Pirlina; Atika,

Handayani, Samsriyaningsih. (2005). Dynamics of Surabaya population – a study of urban population toward Millenium Development Goals achievement, funded by Airlangga University, Indonesian Institute for Human Resources Development and Asian Urban Information Centre of Kobe.

RESEARCH EXPERIENCE Handayani, Samsriyaningsih and Umijati, Sri; Hadiati, Sawitri Retno; Atika (2006). “Studi

pelacakan lulusan Fakultas Kedokteran Universitas Airlangga” (Tracer study of graduates of School of Medicine Airlangga University in Indonesia and other countries), funded by School of Medicine Airlangga University).

Hadiati, Sawitri Rento and Handayani, Samsriyaningsih. (2005). “Upaya bidan di desa

dalam mempromosikan ASI eksklusif di Sidoarjo” (Exclusive breastfeeding promotion by village midwives in Sidoarjo), funded by Airlangga University. The research used qualitative approach and my part was conducting interviews and observations, and analyzing data.

Handayani, Samsriyaningsih and Sulistiawati. (2003). “Pengaruh informasi layanan dokter

umum berpraktek swasta perorangan di Surabaya terhadap kepuasan kliennya” (Effect of information on solo practicing general practitioners’ service in Surabaya on their clients’ satisfaction). Funded by Airlangga University.

Sudibyo, Eddy Pranowo and Soeparto, Hariadi; Handayani, Samsriyaningsih;

Nuswantoro, Djohar; Prajitno, Subur; Budisantosa, Irene; Djuari, Lilik; Sumuljo, Dwi; Wijono, Djoko; Marsoetijati (2000). “Kesiapan rumah sakit di Jawa Timur dalam menghadapi era desentralisasi / otonomi daerah dalam bidang kesehatan” (Hospital preparedness in anticipating decentralization in health sector development in East Java Province”, funded by the World Health Organization.

Handayani, Samsriyaningsih. (1999). “Pengaruh bauran pemasaran jasa dokter berpraktek

swasta perorangan di Surabaya terhadap kepuasan kliennya” (Effects of health service marketing mix application by solo practicing general practitioner in Surabaya on their clients’ satisfaction). Thesis for Master of Health.

Handayani, Samsriyaningsih and Aprilawati, Dwi; Budiono; Dewanti, Linda; Pariani, Siti.

(1996). “Pengelolaan pembiayaan dana sehat oleh berbagai pengumpul dan pengelola dana di Kabupaten Sidoarjo” Community-based health insurance management in City of Sidoarjo, funded by Airlangga University

WORKSHOPS & SEMINARS 2010-2013: Participant at various bi-monthly seminars on HIV, held by Developmental

Chicago Forum for AIDS Research, Chicago, USA.

143

2012: Participant: Seminars and the National Meeting on Social Sciences Network, University of North Carolina at Chapel Hill, USA

2011: Participant: Training on Mixed Method in Research, the 64th Summer Institute in

Survey Research Techniques, University of Michigan in Ann Arbor, USA. 2010: Participant: Course on Principles of STD/HIV Research, held by the University of

Washington in Seattle, USA. 2010: Participant: the Operation Research Mini Course, held by the University of

Washington Center for AIDS and STD – Scientific Program on Health Services and Strategies Research, Seattle, USA.

2009: Participant: Workshop on Strengthening Capacity in HIV/AIDS Research, held by the

Indonesian Epidemiology Network and University of New South Wales, Australia, Surabaya, Indonesia.

2008: Participant: Seminar on the 12 roles of medical teacher, held by the University of

Indonesia in Jakarta, Indonesia. 2008: Participant: Jakarta Meeting in Medical Education – Evaluation on the the

Competency-based Curriculum 2006: Participant: Seminar on Antisipasi Ancaman Flu Burung dan Kejadian Ikutan Pasca

Imunisasi Pada Anak di Jawa Timur (Anticipation of Avian Influenza and Side Effects of Immunization in among Children East Java), held by the Association of East Java Pediatricians)

2005 Participant: Evidence-based Medicine Course, conducted by School of Medicine, University of Indonesia in Jakarta, Indonesia 2004: Participant: Modelling Asian Urban Populations – Environment Dynamics, seminar

held by Airlangga University, Indonesian Institute for Human Resources Development and Asian Urban Information Centre of Kobe, Surabaya, Indonesia

2004: Participant: Simulation model of urban planning using STELLA Software, held by

Airlangga University, Indonesian Institute for Human Resources Development and Asian Urban Information Centre of Kobe, Surabaya, Indonesia

2003: Speaker: Primary Health Care, presented at The 6th National Congress of Indonesian

Family Physician Association, Surabaya, Indonesia. 1999: Participant: Seminar Penyakit Menular Seksual dan Kesehatan Kota (Seminar on

Sexually Transmitted Disease and Urban Health), held by the City of Surabaya Department of Health

1997: Participant: Seminar Asuransi Kesehatan sebagai Alternatif Pembiayaan Kesehatan

dalam Menyongsong Tantangan Abad 21 (Seminar on Health Insurance as a Health Funding Alternative in the 21th Century), held by the Airlangga University School of Public Health and PT Asuransi Kesehatan Indonesia East Java Branch

1996: Participant: Seminar Manajemen Gizi dan Kesehatan Pra Lansa dan Lansia

(Seminar on Nutrition and Health Management for Pre-aged and Aged People)

144

1996: Participant: Pertemuan Tahunan VII Jaringan Epidemiologi Nasional (the 7th Annual Meeting of the Indonesian National Epidemiology Network), held by Jaringan Epidemiologi Nasional and the Ford Foundation in Surabaya

1992: Participant: Kursus Peningkatan Pengetahuan dan Ketrampilan Petugas Puskesmas

dalam Program P2ML terpadu (Course on Upgrading the Knowledge and Skills of Primary Public Health Center Workers in Infectious Diseases Control Program)

OTHER 2013: Team member: Airlangga University Team working to provide inputs to the

Indonesian National Development Planning Body