CSIRO PUBLISHING

Sexual Health, 2018, 15, 246–253

https://doi.org/10.1071/SH17137

HIV susceptibility among clients of female sex workers

in Indonesia: a qualitative inquiry

Lillian Mwanri A, Nelsensius Klau Fauk B,F, Christina Yeni Kustanti C, Atik Ambarwati D
and Maria Silvia Merry E
A
College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia.
B
Institute of Resource Governance and Social Change, Jl. R. W. Monginsidi II, Kupang, East Nusa Tenggara,
Indonesia, 85221.
C
Bethesda Yakkum Health Science Institute, Jl. Johar Nurhadi No. 6, Kota Yogyakarta,
Daerah Istimewa Yogyakarta, Indonesia, 55224.
D
Yayasan Kartini Indonesia, Dukuh Margokerto, Bangsri, Jepara, Jawa Tengah, Indonesia, 59453.
E
Medicine Faculty, Duta Wacana Christian University, Jl. Doktor Wahidin Sudiro Husodo, Yogyakarta,
Indonesia, 55224.
F
Corresponding author. Email: nelsen_klau@yahoo.com

Abstract. Background: The spread of HIV infection among men in Indonesia continues to increase every year. Clients
of female sex workers (FSWs) are a group at higher risk of acquiring HIV infection due to their frequent engagement
in sexual acts with sex workers. This study aimed to identify factors of susceptibility to HIV infection among clients of
FSWs. Methods: A qualitative inquiry using one-on-one in-depth interviews was conducted in the Belu and Malaka
districts of Indonesia from January to April 2017. The study participants (n =42) were the clients of FSWs recruited using
the snowball sampling technique. The inclusion criteria were: being a client of FSWs and being aged 18 years or more.
Data were analysed using a framework analysis. Results: Findings were grouped into two main emerging themes that
included behavioural and socioeconomic factors. Behavioural factors that mediated HIV susceptibility among clients
of FSWs were: frequent engagement in unsafe sex with multiple sex workers; low perceptions of the relevance of
available HIV and AIDS services and limited access to these services; and HIV stigma or fear of being labelled as HIV
positive. Socioeconomic factors included: participants’ economic situation; and individuals’ household responsibility
and ability to afford FSWs services. Conclusions: The study results indicate the need to reformulate and improve HIV and
AIDS-related services, including increasing the level of availability of HIV service points and the dissemination of
knowledge and information about HIV and AIDS and condom use and making them accessible to both FSWs and their
clients in Belu and Malaka districts.

Additional keywords: HIV and AIDS, sexual behaviour, socioeconomic factors, Asia.

Received 17 August 2017, accepted 24 October 2017, published online 15 February 2018

Introduction
The spread of HIV infection in Indonesia has been reported to
have significantly increased over the past 15 years, with East
Java, Jakarta, West Java, Papua and Central Java reported as
provinces with the highest incidence of HIV every year.1 At the
national level, the current national AIDS report shows an
increase in HIV cases from 859 cases in 2005 to 55 848
cases in 2010 and 232 323 cases in 2016.1 The same report
also indicates that during the past 5 years more men were
infected with HIV than women, with men accounting for
59.2% of all infections and women 40.8%.1
Heterosexual sexual engagements have been identified as the
main mode of transmission of HIV in Indonesia when compared
with all other modes of transmission. For example, over the past
5 years the percentage of HIV cases transmitted through
heterosexual contacts was 42.9%, followed by 15.1% through
homosexual contacts and 6.2% through injecting drugs use,
while the rest is unknown.1 Clients of female sex workers
(FSWs) in Indonesia could also be a group at risk of HIV
infection due to their engagement in sexual relations with HIV
high-risk partners or sex workers.2,3 However, evidence on the
spread of HIV and susceptibility factors among this group in
the context of Indonesia is scarce.4–8
Reports and studies in other countries have consistently
reported a higher prevalence of HIV infection among clients
of sex workers compared with the general population, hence they

Journal compilation Ó CSIRO 2018 www.publish.csiro.au/journals/sh

HIV susceptibility factors among clients of FSWs
are considered as a high-risk group for HIV infection.2,3,9–16
Unsafe sex practices with multiple sex workers have been
reported as being among the main factors for HIV
transmission among sex workers’ clients.9,11,14,15,17–21 Other
factors that have been identified as putting this population at
risk are: trusting steady sex worker partners to be HIV free;
interfering with condoms to increase sexual pleasure and
satisfaction; and their belief that condoms are ineffective
against HIV prevention.22 A lack of knowledge and information
on how HIV is transmitted and prevented, the influence of
alcohol and drug use, and early sexual debut have also been
previously reported as factors for non-condom use among sexual
workers’ clients during sexual intercourse.11–15,19,22,23 Other
studies of FSWs’ clients in Indonesia have reported the
following as factors associated with non-condom use to prevent
HIV: poor knowledge of HIV transmission and prevention;
believing in the effectiveness and using prophylactic antibiotics
to prevent HIV; perceived decrease in pleasure and sexual
discomfort when condoms are used; self-perception of being
at low risk of HIV infection; lack of access to condoms
immediately before the sexual act; and perceptions that clean
appearing FSWs are HIV-free.4–8
Although a few studies have been conducted elsewhere in
Indonesia,4–8 these studies used a quantitative method and
were conducted more than a decade ago. In addition, the
National HIV/AIDS Strategy and Action Plan 2003–2007 and
2010–2014 and policy of the Indonesia National AIDS
Commission (which are HIV action plans and policies
targeting the sex industry in Indonesia) focus on behaviour
change communication, management of distribution of
condoms and lubricants, and sexually transmissible infections
(STIs) and HIV management.24,25 However, none of these
national policy drivers appear to translate into service programs
for clients of FSWs in the current study’s settings.1,26,27
Moreover, FSWs and their clients are not officially recognised
as being an at-risk group and thus there has not been targeted
health service delivery for them by the two local governments
in where current study took place.26,27 Because previous
Indonesian studies were conducted more than a decade ago
using a quantitative method that provides limited information,
and their findings have not resulted in local programs, further
studies are needed to provide current information that
specifically targets the sex work industry at the local level.
This qualitative inquiry aimed to identify HIV susceptibility
factors among the clients of FSWs in Indonesia and to provide
newer data that can inform and be used to advocate for
programs that target the sex industry in Belu and Malaka
districts, and possibly the whole of Indonesia.
Methods
Study design
This generic, qualitative, exploratory study used face-to-face
in-depth interviews with 42 clients of FSWs in Indonesia. This
design provided researchers with the opportunity to explore
participants’ concepts, understanding and interpretations of their
behaviours and experiences, and examine how these positioned
them in relation to HIV transmission.28–30 A qualitative design
Sexual Health 247
has also been described to be effective in studying people’s
perspectives in their natural settings,28 hence providing a deep
insight of their real life experiences.28,31,32
Data collection and ethics approval
Study participants were clients of FSWs in Belu and Malaka
districts, Indonesia. They were recruited using the snowball
sampling technique. Four initial participants were recruited
with the help of staff at a non-government organisation
providing HIV and AIDS services in the districts. After
receiving the study information sheet disseminated through
the non-government organisation staff, prospective participants
contacted one of the researchers (NKF) and stated their
willingness to participate in the study. The four initial
participants also helped to disseminate the study information
sheet to their friends who may be willing to participate. Eighteen
participants were interviewed at the second stage and then
these participants disseminated information to more prospective
participants. Twenty participants took part in the third stage
interviews. The inclusion criteria for participation were: (i) being
a client of FSWs; and (ii) being 18 years or more.
Interviews were conducted from January to April 2017
using an in-depth interview method28 at a time and place
recommended by participants. Before the interviews participants
were advised about the aim of the study and that the interview
would be audio recorded using a tape recorder. Participants
were also informed of the voluntary participatory nature of the
study and that there would be no consequences if they chose
to not participate. They were also assured of the anonymity
and confidentiality of the collected information. Each participant
was assigned a study identification letter and number (e.g.
P1, P2) for de-identification purposes. After receiving this
information each participant signed and returned a written
informed consent form before the commencement of
interviews. The interviews were conducted in Bahasa. Ethics
approval was obtained from the Medicine Research Ethics
Committee, Duta Wacana Christian University, Yogyakarta,
Indonesia (reference 386/C.16/FK/2017).
Data analysis
Interviews were transcribed verbatim and translated into
English by two authors (NKF and CYK). The two authors
also cross-checked the data for accuracy and clarity during the
transcription and translation process. The analysis used Ritchie
and Spencer’s framework analysis following five steps:33
(i) familiarisation with the data or transcripts (as outlined
above); (ii) identification of a thematic framework (where
recurrent key issues, concepts and themes were written
down); (iii) indexation of all the data (open coding followed
by closed coding was conducted where codes referring to the
same theme were grouped together to reach a few overarching
themes); (iv) charting the data (through arrangement of
appropriate thematic references in a summary chart); and
(v) data mapping and interpretation(to examine the ideas that
made up the main themes in order to see the relationship and
association between them).33–35 The use of the framework in
this analysis process contributes to qualitative data management
248 Sexual Health
in a systematic way and enhances rigour, transparency,
consistency and structure of the data.33,36 In this data analysis
process both inductive and deductive approaches with
categories emerging purely from the data and derived from
prior knowledge were used.37
Results
Sociodemographic characteristics of the participants
The mean age of the study participants was 26.7 years.
The majority of them were single (93%) and had graduated
from high school (83%). A few of them (17%) were elementary
school graduates. Participants worked in various jobs including
as motorcycle taxi drivers (36%), construction workers (33%)
and port workers (24%). Sixty two percent of them reported
having had more than 11 sexual encounters with FSWs in
the past 6 months, 26% percent had 6–10 encounters and 12%
had 1–5.
Knowledge and behavioural factors
Frequent engagement in unprotected sexual practices
Unsafe sexual practices were discovered to be one of the
main contributors to participants’ susceptibility to HIV infection.
Frequent engagement in unprotected sex with multiple FSWs
was reported to be common among the majority of participants,
hence enhancing their susceptibility to acquiring HIV. Lack
of knowledge of condoms and their protective functions
against HIV transmission and other STIs was one of the
main factors for their consistent engagement in sex without
condoms:
‘I do not use condoms at all because I know
nothing about condoms.’ (P10, 30 years old,
single)
‘I never use it [condom]. I do not know about
condom and its functions.’ (P11, 19 years old,
single)
‘Never heard of it [condom] prior to this
interview.’ (P39, 28 years old, married)
‘I have seen it [condom] once but I do not know
what to do with it.’ (P28, 21 years old, single)
Other factors, including lack of availability of condoms when
needed, feeling uncomfortable about purchasing condoms, and
pressure from friends and peers to not use condoms played
a significant role in preventing condom use among clients of
FSWs. All the interviewees who used condoms inconsistently
acknowledged these factors as barriers to condom use:
‘I often use condom every time I have sex with
sex workers but if condoms are not available at
the time I am already with her, then I do not use
it.’ (P4, 22 years old, single)
‘If I am already with her [FSW] and there is
no condom, then I do not use.’ (P22, 35 years
old, married)
L. Mwanri et al.
‘I always think of using condom once planning
to have sex with them [FSWs] at the brothel
but sometimes I could not buy condoms
because I feel uncomfortable.’ (P12, 19 years
old, single)
‘I feel ashamed every time I buy condoms
because people stare at me. This is the reason
why I do not always have condoms available to
use.’ (P29, 24 years old, single)
‘My colleagues sometimes succeed to convince
me to not use condoms when we go to have
sex with the sex workers.’ (P38, 31 years old,
single)
Low perceptions of the relevance of available
HIV- and AIDS-related services and limited
access to these services
Perceived low relevance of available HIV- and AIDS-
related services was another behavioural factor for the
susceptibility of the clients of FSWs to HIV infection. For
example, services such as Voluntary Counselling and HIV
testing, HIV- and AIDS-related information services and free
condom provision were made available to people in the two
districts but study participants were unwilling to access
them. Several study participants who knew about these
services said they had never accessed them. The fact that
they never accessed these services, as illustrated by the
following participant statements, might have precluded them
from knowing their HIV status, hence increasing HIV
vulnerability among them.
‘I have heard of the counselling and HIV testing
and I know the place where such service is
provided but I never go there because I do
not want to do the counselling and testing.’
(P32, 23 years old, single)
‘I heard about the availability of condoms at the
AIDS commission office but I never go there to
take them. I can go there and ask for condoms
but I just don’t do it so far.’ (P8, 32 years old,
single)
‘I do not access HIV/AIDS services, why should
I do that?’ (P41, 33 years old, single)
‘I feel healthy, I do not need it [HIV and AIDS
services].’ (P30, 24 years old, married)
Lack of awareness of the available HIV and AIDS-related
services, living far away from the service delivery points, and
fear of talking about HIV and AIDS were common reasons for
not accessing HIV and AIDS-related services:
‘I do not know at all about HIV/AIDS services.’
(P20, 22 years old, single)
‘Nobody told me about HIV/AIDS services.’
(P26, 28 years old, single)
HIV susceptibility factors among clients of FSWs
‘I was told about HIV testing and free condoms,
but it is too far from here, so I do not go there
yet.’ (P18, 29 years old, single)
‘It is in the city, far from here.’ (P2, 22 years old,
single)
‘I do not want to access the services because
I am afraid of talking about HIV/AIDS and
I do not even know what to say if I meet
a counsellor.’ (P33, 34 years old, single)
‘I do not go there because I do not have courage
to talk about it with the experts.’ (P5: 28 years
old, single)
HIV stigma and fear of being labelled as HIV positive
HIV stigma or fear of being labelled as an HIV- or AIDS-
positive person emerged in the interviews as another important
factor that influenced the healthcare-seeking behaviour of the
clients of FSWs. This fear discouraged them from visiting HIV
and AIDS service delivery points and consulting with health
workers, hence increasing the possibility of HIV and other STI
transmission among them.
‘I never go to the service delivery point, I am
afraid that people who see me could think that
I am HIV positive’ (P35, 30 years old, single)
‘I know about the [HIV/AIDS] services but I feel
uncomfortable to visit that place, people will
directly notice and be suspicious about me.’
(P42, 27 years old, single)
‘I will not go there, they [healthcare workers]
could think that I am an HIV positive.’ (P15,
31 years old, single)
HIV stigma was also cited as a reason that these clients of FSWs
did not undergo HIV testing, which would enable them to know
their HIV status. Several study participants who knew about
Voluntary Counselling and HIV testing commented that being
HIV positive made them worry about being discriminated
against both by people who knew their HIV status (service
providers) as well as by their family members. Such fear
precluded them from knowing their HIV status and seeking
early treatment if infected, hence escalating their susceptibility
to HIV transmission.
‘I attended the HIV/AIDS session a few times
so I know about the HIV/AIDS services. I once
thought of undergoing HIV testing but I was
scared because it would be a very big problem
for me if I am positive, people and also my family
members could avoid me.’ (P19, 21 years old,
single)
‘I am not afraid of taking HIV testing but the
consequence if I get infected with HIV. I have
seen it on an HIV-positive person in my
community. It seems like he just disappeared.
People said he just stays at home, never goes
Sexual Health 249
out. I think he knows that people talk about his
HIV status and he feels uncomfortable to get out
from his house’ (P37, 24 years old, single)
‘I am afraid [to undergo HIV testing]. People
will react negatively or say negative things
about me if I have HIV. I think people would
feel scared even just to shake hand with me.’
(P9, 26 years old, single)
Socioeconomic factors
Participants’ economic conditions
Economic situation seemed to be a significant factor in
participants’ sexual behaviour. Participants whose socioeconomic
status was good appeared to have frequent sexual engagements
with multiple FSWs. Disposable cash income from their work as
motorcycle taxi drivers, construction workers and port workers
was used to support regular sexual encounters with FSWs in the
places where they worked or lived. This regular exposure had
the potential to increase their susceptibility to HIV infection
since condom use was often inconsistent.
‘Maybe because I always have cash in my
pocket every day, so if I want to have sex
with the sex workers then I can always do it.
I pay them so I do not want to use condoms.’
(P23, 26 years old, single)
‘I do not have financial difficulties; I drive
passengers every day and always have money
even though it is not that much. I can do
everything I want including having sex with
them. I often bring condoms because I know
they do not provide condoms, but sometimes I do
not use if I forget to bring.’ (P25, 23 years old,
single)
‘At least I can pay for that [sex with FSWs]
every time I want, I mean I have money because
I am working. Sometimes I use condoms.’ (P31,
26 years old, single)
On the other hand, however, the price of condoms was
a prohibitive factor associated with some participants’ low
level or lack of using condoms. A few participants who had
low cash flow found condoms to be expensive. As such, they
were unwilling to purchase condoms and engaged in unsafe
sexual activity with FSWs, hence heightening their susceptibility
to HIV infections.
‘I once wanted to buy condoms but I cancelled
because I did not have enough cash at that time.
The prices were more than what I expected.’
(P39, 28 years old, married)
‘I know the pharmacies sell condoms but to my
opinion they are too expensive.’ (P17, 30 years
old, single)
‘I buy condoms but not that often because the
prices are quite high.’ (P24, 23 years old, single)
250 Sexual Health
Individuals’ household responsibility and affordability
of FSWs’ services
The ability to pay for sex seemed to be facilitated by the
affordability of FSWs and individuals’ household responsibility.
Having less financial responsibility for household needs or
children’s school fees and being single put study participants
in a better financial situation. Such conditions were reported to
support the participants’ choices of activities including to engage
in sex with FSWs, hence increasing their susceptibility to HIV
infection as well as other STIs.
‘I just take care of myself, I am single so I can
spend my money for whatever I want to, not like
married people who should be responsible for
their household needs and the school fees of
their children.’(P6, 20 years old, single)
‘I am single, I am not responsible for anybody
else, I guess it is the time for me to enjoy what I
want including sex because I think it would be
impossible after getting married.’ (P36, 28 years
old, single)
‘I am free to do that [have sex with sex workers],
I do not have kids whom I should be responsible
for.’ (P16, 29 years old, single)
Additionally, the cost of sex that was charged by FSWs was
another enabling factor for the study participants to frequently
visit FSWs. All the interviewees acknowledged that the cost of
sex charged by FSWs was affordable or low and negotiable:
‘I do not think of losing money if I pay to have
sex with a sex worker because the charge is not
much. I can afford it and I think everybody can
afford it if they want.’(P20, 22 years old, single)
‘It is cheap [to have sex with sex workers] and
negotiable. I always bargain the price before
having sex with the sex workers.’ (P14, 27 years
old, single)
‘Sometimes I give only 20 000 to 25 000 rupiahs
[~US$1.5–2]. I can do it anytime I want because
it is affordable.’ (P30, years old, married)
Discussion
This study identified factors that contributed to the susceptibility
of the clients of FSWs to HIV infection. Supporting the results
of several previous studies,4,9,11,12,14,15,17–21,26,38,39 the current
findings report frequent engagement in unprotected sex with
multiple FSWs as a common practice among both single and
married men. Consistent with similar studies where married men
have been reported to engage in sex without condoms with
FSWs,26,38 the only three married participants in the present
study also acknowledged their regular unprotected sexual
encounters with FSWs due to a myriad of factors such as
perceived low risk of HIV susceptibility, low perceptions of
the relevance of HIV services and perceived high cost of
condoms. These findings support the Health Belief Model
L. Mwanri et al.
used in health promotion, which theorises that the possibility
of individuals adopting or undertaking actions against a
perceived health threat is subject to their beliefs relating to
four key components, including perceived susceptibility to the
threat, perceived severity of the threat, perceived benefits and
perceived barriers or cost against their actions.40,41 Similarly
supportive of previous studies,7,8,12,14,26,38,39 this study found
that the lack of knowledge of condoms and their protective
function against HIV transmission, unavailability of condoms
at the time of need, feeling uncomfortable about purchasing
condoms, and peers influence, were the overarching factors that
determined unsafe sexual behaviours and practices among the
clients of FSWs. Low perceptions of the relevance of available
HIV- and AIDS-related services and limited access to these
services also supported unsafe sexual behaviours, predisposing
clients of FSWs to HIV infections. The findings of the present
study also confirm the results of previous studies including by
Safika and colleagues,42,43 Wahdini and Isarabhakdi,44
Diarsvitri et al.,45 Basuki et al.,46 Butt and Munro,47 Pisani
et al.48 and Hull et al.,49,50 which have reported low or no
condom use among different at-risk populations in Indonesia,
such as sex workers, adolescents, senior high school students,
men who have sex with men, and male-to-female transgender.
In particular, the present findings indicate that HIV- and AIDS-
awareness raising campaigns, especially on condom use, as
well as basic knowledge of HIV and AIDS have not been
effective enough to effect positive behavioural change among
at-risk groups, including clients of FSWs. Moreover, these
findings support the claim made in the recent National HIV/
AIDS Strategy and Action Plan 2010–2014 that HIV infection
prevention through condom use is not yet effective among
high-risk populations, including FSWs, clients of FSWs,
male-to-female transgender and men who have sex with
men.24 For successful prevention of HIV infections in
Indonesia factors that are known to enhance susceptibility of
HIV, such as the lack of awareness of the availability of the
services, unwillingness to access the services, living far away
from the service delivery points and fear of talking about HIV
and AIDS26 must be addressed.
HIV stigma and fear of being labelled as HIV-positive
by people, including family members, was also reported as
a significant influence on participants’ healthcare-seeking
behaviour. It precluded them from accessing available HIV
and AIDS-related services and undergoing from HIV testing
in particular, hence increasing the likelihood of HIV
transmission among them. Similar findings have also been
reported before,26,51–55 indicating that HIV stigma needs to
be addressed if we expect improvements in HIV-related
health-seeking behaviours among various at-risk groups. The
influence of alcohol and drugs, consumption of prophylactic
antibiotics before sexual intercourse and a distrust of
condoms for HIV prevention that have been reported in
previous studies as reasons for inconsistent or no condom
use among the clients of FSWs,5,8,11–15,22 were not seen in
the present study. Likewise, social supports from family and
friends reported in the results of a previous study as supporting
factors for condom use among clients of FSWs20 were not
established in the current study.
HIV susceptibility factors among clients of FSWs
The findings of the present study also demonstrate that the
good financial situation and affordability of FSWs for high-
income earners, such as construction workers, truck drivers and
motorcycle taxi drivers, are enabling factors for frequent
engagement in sex with multiple FSWs. As in previous studies,
inconsistent condom use was observed in this study among
clients of FSWs who frequently engage in sex with multiple
partners, increasing their susceptibility to HIV transmission.38,56,57
In addition, other factors such as being single, having less
responsibility for household needs or children’s school fees
and the low cost of sex with FSWs supported participants’
frequent engagement in unsafe sex with multiple FSWs,
potentially enhancing their susceptibility to HIV acquisition.
These findings need to be interpreted with caution, as there
were study limitations. Participants involved in this study were
recruited from two neighbouring districts that used to be one
district before being divided in 2012. Therefore, the findings
reflect the situation of participants from two districts with
very similar characteristics in terms of education level and
types of jobs. As such, these findings may not be
transferrable to other clients of FSWs in other sites, as they
may have different characteristics.
Despite its limitations, to our knowledge the current study
is the first qualitative investigation to explore factors that
enhance susceptibility to HIV transmission among the clients
of FSWs in Indonesia. The findings of this study offer
insights that may lead health workers and HIV and AIDS
practitioners to tackle HIV and AIDS among the clients of
FSWs and the FSWs themselves. Future studies that involve
larger numbers of participants with different characteristics
and from different sites are recommended.
Conclusions
The present study reports several behavioural and socioeconomic
factors that contribute to the susceptibility of the clients of
FSWs to HIV infection. Frequent engagement in unprotected
sex due to lack of knowledge of condoms and their protective
functions, unavailability of condoms when needed, the
discomfort associated with the purchase of condom and peer
influence were the main behavioural factors found to increase
participants’ susceptibility to HIV infection. Additional factors
enhancing susceptibility to HIV transmission among participants
identified in the present study included: low perception of the
relevance of available HIV- and AIDS-related services, limited
access to these services, lack of awareness of the availability of
the services, living far away from the service delivery points,
and HIV stigma and fear of being labelled as HIV positive.
Affordability of FSWs and low level of individuals’ financial
responsibility were enablers of frequent engagement with
multiple partners, potentially increasing the susceptibility of
these clients to HIV transmission. In concluding, it is
reasonable to state that the present study has uncovered a set
of factors that enhance participants’ susceptibility to HIV
transmission. The findings highlight the need to reformulate
and improve HIV and AIDS awareness-raising campaigns and
HIV- and AIDS-related services, including increasing the level
of availability of HIV service points of care. Dissemination
of knowledge and information about HIV and AIDS and the
Sexual Health 251
importance of condoms is also necessary. Additionally, making
condoms easily accessible to both FSWs and their clients
would be one beneficial strategy to combat HIV among the
clients of FSWs in Indonesia and beyond.
Conflicts of interest
The authors declare no conflicts of interest.
References
1 Kementrian Kesehatan Republik Indonesia. LaporanSituasiPerkembangan
HIV/AIDS & PIMS di Indonesia, Oktober-Desember 2016. Jakarta:
Kementrian Kesehatan Republik Indonesia; 2016. Available at: http://
www.aidsindonesia.or.id/ck_uploads/files/Final%20Laporan%20HIV
%20AIDS%20TW%204%202016.pdf [verified 29/11/2017].
2 World Health Organization. Understanding the modes of transmission
model of new HIV infection and its use in prevention planning.
Geneva, Switzerland: World Health Organization; 2012.
3 World Health Organization. Executive summary of the global update
on the health sector response to HIV. Geneva: World Health
Organization; 2014.
4 Thorpe L, Ford K, Fajans P, Wirawan DN. Correlates of condom
use among female prostitutes and tourist clients in Bali, Indonesia.
AIDS Care 1997; 9(2): 181–97. doi:10.1080/09540129750125208
5 Ford K, Wirawan DN, Muliawan P. Social influence, AIDS/STD
knowledge, and condom use among male clients of female sex
workers in Bali. AIDS Educ Prev 2002; 14(6): 496–504. doi:10.1521/
aeap.14.8.496.24113
6 Ford K, Wirawan DN, Fajans P, Meliawan P, MacDoanald K, Thorpes
L. Behavioral interventions for reduction of sexually transmitted
disease/HIV transmission among female commercial sex workers
and clients in Bali, Indonesia. AIDS 1996; 10: 213–22. doi:10.1097/
00002030-199602000-00013
7 Fajans P, Wirawan DN, Ford K. STD knowledge and behaviours
among clients of female sex workers in Bali, Indonesia. AIDS Care
1994; 6(4): 459–75. doi:10.1080/09540129408258661
8 Fajans P, Ford K, Wirwan DN. AIDS knowledge and risk behaviors
among domestic clients of female sex workers in Bali, Indonesia. Soc
Sci Med 1995; 41(3): 409–17. doi:10.1016/0277-9536(94)00327-P
9 Shaw SY, Bhattacharjee P, Isac S, Deering KN, Ramesh BM,
Washington R, Moses S, Blancharrd JM. A cross-sectional study
of sexually transmitted pathogen prevalence and condom use with
commercial and noncommercial sex partners among clients of female
sex workers in Southern India. Sex Transm Dis 2013; 40(6): 482–9.
doi:10.1097/OLQ.0b013e3182904a9a
10 Shaw SY, Deering KN, Reza-Paul S, Isac S, Ramesh BM, Washington
R, Moses S, Blanchard JM. Prevalence of HIV and sexually
transmitted infections among clients of female sex workers in
Karnataka, India: a cross-sectional study. BMC Public Health 2011;
11(Suppl 6): 1–8.
11 Couture MC, Soto JC, Akom E, Labbe AC, Joseph G, Zunzunegui
MV. Clients of female sex workers in Gonaives and St-Marc, Haiti
characteristics, sexually transmitted infection prevalence and risk
factors. Sex Transm Dis 2008; 35(10): 849–55. doi:10.1097/
OLQ.0b013e318177ec5c
12 Xu JJ, Wang N, Lu L, Pu Y, Zhang GL, Wong M, Wu ZL, Zheng XW.
HIV and STIs in clients and female sex workers in mining regions of
Gejiu City, China. Sex Transm Dis 2008; 35(6): 558–65. doi:10.1097/
OLQ.0b013e318165926b
13 Papworth E, Ceesay N, An L, Thiam-Niangoin M, Ky-Zerbo O,
Holland C, Drame FM, Grosso A, Diouf D, Baral SD. Epidemiology
of HIV among female sex workers, their clients, men who have sex with
men and people who inject drugs in West and Central Africa. AIDS
2013; 16(Suppl 3): 1–11.
252 Sexual Health
14 Nguyen NT, Nguyen HT, Trinh HQ, Mills SJ, Detels R. Clients of
female sex workers as a bridging population in Vietnam. AIDS Behav
2009; 13(5): 881–91. doi:10.1007/s10461-008-9463-4
15 Jin X, Smith K, Chen RY, Ding G, Yao Y, Wang H, Qian H-Z, Chang
D, Wang G, Wang N. HIV prevalence and risk behaviors among
male clients of female sex workers in Yunnan, China. J Acquir
Immune Defic Syndr 2010; 53(1): 131–5. doi:10.1097/QAI.0b013e
3181b3552a
16 McLaughlin MM, Chow EPF, Wang C, Yang L-G, Yang B, Huang
JZ, Wang Y, Zhang L, Tucker JD. Sexually transmitted infections
among heterosexual male clients of female sex workers in China:
a systematic review and meta-analysis. PLoS One 2013; 8(8): e71394.
doi:10.1371/journal.pone.0071394
17 Miller GA, Mendoza W, Krone MR, Meza R. Clients of female sex
workers in Lima, Peru: a bridge population for sexually transmitted
disease/HIV transmission? Sex Transm Dis 2004; 31(6): 337–42.
doi:10.1097/00007435-200406000-00003
18 Ramanathan S, Nagarajan K, Ramakrishnan L, Mainkar MK,
Goswami P, Yadav D, Sen S, Goerge B, Rachakulla H,
Subramanian T, Paranjape RS. Inconsistent condom use by male
clients during anal intercourse with occasional and regular female
sex workers (FSWs): survey findings from southern states of India.
BMJ Open 2014; 4: e005166. doi:10.1136/bmjopen-2014-005166
19 Couture MC, Soto JC, Akom GJE, Zunzunegui MV. Determinants
of intention to use condoms among clients of female sex workers
in Haiti. AIDS Care 2010; 22(2): 253–62. doi:10.1080/09540120
903111478
20 Volkmann T, Wagner KD, Strathdee SA, Semple SJ, Ompad DC,
Chavarin CV, Patterson TL. Correlates of self-efficacy for condom
use among male clients of female sex workers in Tijuana, Mexico. Arch
Sex Behav 2014; 43(4): 719–27. doi:10.1007/s10508-013-0149-2
21 Suryawanshi D, Bhatnagar T, Deshpande S, Zhou W, Singh P,
Collumbien M. Diversity among clients of female sex workers
in India: comparing risk profiles and intervention impact by site of
solicitation. Implications for the vulnerability of less visible female sex
workers. PLoS One 2013; 8(9): e73470. doi:10.1371/journal.pone.
0073470
22 Voeten HACM, Egesah OB, Ondiege MY, Varkevisser CM,
Habbema JDF. Clients of female sex workers in Nyanza Province,
Kenya: a core group in STD/HIV transmission. Sex Transm Dis 2002;
29(8): 444–52. doi:10.1097/00007435-200208000-00003
23 Fauk NK, Mery MS, Sigilipoe MA, Putra S, Mwanri L. Culture, social
networks and HIV transmission among men who have sex with men
in Indonesia. PLoS One 2017; 12(6): e0178736. doi:10.1371/journal.
pone.0178736
24 Minister for People’s Welfare – Republic of Indonesia. The national
HIV and AIDS strategy and action plan 2010 – 2014. Jakarta: Minister
for People’s Welfare – Republic of Indonesia; 2009. Available at
http://www.ilo.org/wcmsp5/groups/public/—ed_protect/—protrav/—
ilo_aids/documents/legaldocument/wcms_173075.pdf [verified 29/
11/2017].
25 Indonesia National AIDS Commission. Republic of Indonesia country
report on the follow up to the declaration of commitment on
HIV-AIDS (UNGASS), 2010–2011. Jakarta: Indonesia National
AIDS Commission; 2012. Available at: http://www.kebijakanaids
indonesia.net/id/dokumen-kebijakan/send/6-publikasi-publication/
470-republic-of-indonesia-country-report-on-the-follow-up-to-the-
declaration-of-commitment-on-hiv-aids-ungass-2010-2011 [verified
29/11/2017]
26 Fauk NK, Mwanri L. Inequalities in addressing the HIV epidemic:
the story of the Indonesia Ojek community. International Journal
of Human Rights in Healthcare 2015; 8(3): 144–59. doi:10.1108/
IJHRH-10-2014-0028
L. Mwanri et al.
27 Komisi Penanggulangan AIDS Daerah Belu. Laporan Data HIV/AIDS
Kabupaten Belu s/d Desember 2016 [Report on HIV/AIDS cases in
Belu district up to December 2016]. Atambua: Komisi Penanggulangan
AIDS Daerah Belu; 2017.
28 Rice PL, Ezzy D. Qualitative research method: a health focus.
Melbourne: Oxford University Press; 2005.
29 Allsop J. Competing paradigms and health research: design and
process. In Saks M, Allsop J, editors. Researching health, qualitative,
quantitative and mixed methods. London: Sage; 2013.
30 Heyink JW, Tymstra TJ. The function of qualitative research. Soc
Indic Res 1993; 29(3): 291–305. doi:10.1007/BF01079517
31 Coreil J. Group interview methods in community health research.
Med Anthropol 1994; 16: 193–210. doi:10.1080/01459740.1994.
9966115
32 Marvasti AB. Qualitative research in sociology: an introduction.
California: Sage; 2004.
33 Ritchie J, Spencer L. Qualitative data analysis for applied policy
research. In Bryman A, Burgess RG, editors. Analyzing qualitative
data. London: Routledge; 1994. p. 173–94.
34 Berkman LF, Glass T, Brissette I, Seeman TE. From social integration
to health: Durkheim in the new millennium. Soc Sci Med 2000; 51:
843–57. doi:10.1016/S0277-9536(00)00065-4
35 Fauk NK, Mwakinyali SE, Putra S, Mwanri L. Understanding
the strategies employed to cope with increased numbers of AIDS-
orphaned children in families in rural settings: a case of Mbeya Rural
District, Tanzania. Infect Dis Poverty 2017; 6(1): 21.
36 Srivastava A, Thomson SB. Framework analysis: a qualitative
methodology for applied policy research. Journal of Administration
and Governance 2009; 4(2): 72–9.
37 Moretti F, van Vliet L, Bensing J, Deledda G, Mazzi M, Rimondini M,
Zimmermann C, Fletcehr I. A standardized approach to qualitative
content analysis of focus group discussions from different countries.
Patient EducCouns 2011; 82(3): 420–8. doi:10.1016/j.pec.2011.
01.005
38 Fauk NK, Mwanri L. Economic and environmental determinants
of Ojek’s susceptibility to HIV infection. International Journal of
Pharma and Bio Sciences 2014; 3(1): 291–300.
39 Fauk NK, Crutzen R, Merry MS, Putra S, Sigilipoe MA, Mwanri L.
Exploring determinants of unprotected sexual behaviours favouring
HIV transmission among men who have sex with men in Yogyakarta,
Indonesia. Glob J Health Sci 2017; 9(8): 47–56. doi:10.5539/gjhs.
v9n8p47
40 Redding CA, Rossi JS, Rossi SR, Velicer WF, Prochaska JO.
Health behaviour models. Int Electron J Health Educ 2000;
3(special issue): 180–93.
41 Richardson CA, Rabiee F. A question of access: an exploration
of the factors that influence the health of young males aged 15 to
19 living in Corby and their use of health care services. Health Educ
J 2001; 60(1): 3–16. doi:10.1177/001789690106000102
42 Safika I, Levy JA, Johnson TP. Sex work venue and condom use
among female sex workers in Senggigi, Indonesia. Cult Health Sex
2013; 15(5): 598–613. doi:10.1080/13691058.2013.776112
43 Safika I, Johnson TP, Cho YI, Praptoraharjo I. Condom use among
men who have sex with men and male-to-female transgendersin
Jakarta, Indonesia. Am J Mens Health 2014; 8(4): 278–88.
doi:10.1177/1557988313508430
44 Wahdini M, Isarabhakdi P, editors. Safe sexual behavior: the use
of condom among never married male adolescents in Indonesia. 4th
Asian Academic Society International Conference; 12–13 May 2016;
Nakhon Pathom, Thailand.
45 Diarsvitri W, Utomo ID, Neeman T, Oktavian A. Beyond sexual
desire and curiosity: sexuality among senior high school students in
Papua and West Papua Provinces(Indonesia) and implications for
HIV susceptibility factors among clients of FSWs
HIV prevention. Cult Health Sex 2011; 13(9): 1047–60. doi:10.1080/
13691058.2011.599862
46 Basuki E, Wolffers I, Devillé W, Erlaini N, Luhpuri D, Hargono R,
Maskuri N, Suesen N, van Beelen N. Reasons for not using condoms
among female sex workers in Indonesia. AIDS EducPrev 2002; 14(2):
102–16. doi:10.1521/aeap.14.2.102.23901
47 Butt L, Munro J. Rebel girls? Unplanned pregnancy and colonialism in
highlands Papua, Indonesia. Cult Health Sex 2007; 9(6): 585–98.
doi:10.1080/13691050701515324
48 Pisani E, Girault P, Gultom M, Sukartini N, Mustiwatik ED, Jazan J,
Donegan S. HIV, syphilis infection, and sexual practices among
transgenders, male sex workers, and other men who have sex with
men in Jakarta, Indonesia. Sex Transm Infect 2004; 80: 536–40.
doi:10.1136/sti.2003.007500
49 Hull TH, Adioetomo SM. Women, family planning and decentralisation:
new variations on old themes. In Robinson K and Bessell S (editors).
Women in Indonesia: gender, equity and development. Singapore:
Institute of Southeast Asian Studies; 2002.
50 Hull TH, Hull VJ. Changing marriage behaviour in Java: the role
of timing of consummation. Southeast Asian J Soc Sci 1987; 15(1):
104–19. doi:10.1163/080382487X00082
51 Churcher S. Stigma related to HIV and AIDS as a barrier to accessing
health care in Thailand: a review of recent literature. WHO South East
Asia J Public Health 2013; 2(1): 12–22.
www.publish.csiro.au/journals/sh
Sexual Health 253
52 Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma
in health care settings: what works? J Int AIDS Soc 2009; 12(15).
doi:10.1186/1758-2652-12-15
53 Feyissa GT, Abebe L, Girma E, Woldie M. Stigma and discrimination
against people living with HIV by healthcare providers, Southwest
Ethiopia. BMC Public Health 2012; 12(522).
54 Dasgupta S, Sullivan PS, Dasgupta A. Stigma and access to HIV care
among HIV-infected women in Kolkata, West Bengal. J Int Assoc
Provid AIDS Care 2013; 12(1): 44–9. doi:10.1177/1545109711
401410
55 Zamberia AM. HIV-related stigma and access to health care among
people living with HIV in Swaziland. Dev South Afr 2011; 28(11):
669–80. doi:10.1080/0376835X.2011.623914
56 Asian Development Bandk (ADB). Roads and HIV/AIDS, a resource
book for the transport sector. Mandaluyong: Asian Development
Bank; 2008.
57 Byron E, Gillespie S, Hamazakaza P. Local perceptions of HIV risk
and prevention in southern Zambia. Washington, D.C.: International
Food Policy Research Institute; 2006.
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