Estimation of Potential HIV Transmission Risk in Recent Anal Intercourse Events among Men Who Have Sex with Men and Transgender Women in Bali, Indonesia

Abstract

In recent years, prevalence of Human Immunodeficiency Virus (HIV) has increased substantially in Bali, Indonesia, in men who have sex with men (MSM) and transgender women, known locally as ‘waria’. There are limited behavioural data in this population. We conducted a behavioural survey of MSM/waria in Bali in March–April 2018. Respondents were primarily recruited by HIV outreach workers. Respondents reported details about anal intercourse events with their last male/waria romantic partner and/or last male/waria casual partner (respondents could report on both if relevant). Statistical significance was tested with generalised estimating equations. Among 709 participants, median age was 27 (interquartile range = 24–31), and 92.1% were male and 7.9% were waria. One-third were born in Bali. Overall, 85.9% had ever had an HIV test; 55.1% reported being HIV-negative, 15.0% HIV-positive, and 30.0% had unknown serostatus. Most (86.5%) reported sex with men, 9.5% with waria, and 20.0% with women in the previous 6 months. Respondents described 703 anal intercourse events (397/306 with romantic/casual partners, respectively; 191 reported on both). Over half (56.5%) of the events were protected by condoms and 7.3% by biomedical prevention (2.6% by PrEP in either partner, 4.7% by HIV treatments in either partner). Thus, 36.3% of events involved unprotected condomless anal intercourse (40.8%/30.4% in romantic/casual partners, respectively). In multivariate analysis, unprotected condomless anal intercourse events were associated with romantic partners (p < 0.001), being born in Bali (p = 0.002), lower education (p = 0.013), believing that withdrawal before ejaculation is effective (p < 0.001), liking to use withdrawal (p = 0.021), and not liking condoms (p < 0.001). One-quarter of events had potentially reduced HIV transmission risk through non-condom-based risk reduction strategies, while 11.1% had no potential risk reduction. Events presenting the highest potential risk of HIV transmission were more commonly reported by respondents born in Bali.

Inconsistent condom use with casual partners among men who have sex with men in Brazil: a cross-sectional study

“…Our results indicate that even in casual relationships, in which condom use tends to be higher compared to those involving steady partners, there is still a significant percentage of MSM who do not use condoms (50.8%) consistently, increasing the level of exposure to HIV and other STIs. This prevalence was higher than in other studies, such as that by Ulrich et al 20 , conducted in Peru, where 20% of MSM that had more than one partner reported condomless anal intercourse (CLAI) with all of them, or Bavinton et al 21 , where the prevalence was 30.4% for casual partners in MSM in Bali, Indonesia.…”

Understanding Women’s Knowledge, Awareness, and Perceptions of STIs/STDs in Asia: A Scoping Review

“…This is due to the lack of awareness amongst them when it comes to protection and information on contraception. Furthermore, in some parts of Asia, contraception may be difficult to access [45,59,75], expensive [39], and in some cases prove to be a taboo [7]. This can make it challenging for women to use protection consistently.…”

Characterizing Socioecological Markers of Differentiated HIV Risk Among Men Who Have Sex with Men in Indonesia

“…In addition, the wide use of online social networks to meet sexual partners facilitates sexual risk behavior in this group [ 15 ]. This creates an environment that limits disclosure of risk practices (e.g., multiple sex partners [ 16 ], sexualized drug use (SDU) [ 17 ]), and missed opportunities to access HIV prevention and other sexual health programs for MSM [ 18 ]. This becomes more problematic in the context of low levels of HIV viral suppression, inadequate knowledge of HIV prevention and treatment, and poor coverage of HIV PrEP [ 19 ].…”

“…Despite the socioecological and HIV-related epidemiological and behavioral contexts for MSM in Indonesia [ 20 ], there has been little research on their combined contribution to shaping overall HIV risk. Most studies of MSM in Indonesia have focused on describing individual behaviors as drivers of risk, such as condomless anal intercourse (CAI) as a driver of HIV risk, the role of HIV status in influencing risk behaviors, and the effect of HIV knowledge on unsafe sex [ 16 , 21 , 22 ]. Some studies have begun to recognize the contribution of social and structural factors to HIV risk [ 23 ], but have not directly assessed their links with individual risk behaviors and sexual practices.…”