PrEP Use Awareness and Interest Cascade among MSM and Transgender Women Living in Bali, Indonesia

Abstract

Indonesia has not implemented HIV pre-exposure prophylaxis (PrEP) despite global calls for its scale-up, and there is limited information about attitudes towards PrEP among its potential users. We aim to present a PrEP cascade among men who have sex with men (MSM) and transgender women (known locally as “waria”) in Denpasar, Bali, from a cross-sectional survey with 220 HIV-negative MSM/waria recruited from one clinic in Denpasar. Only 16.4% of participants had heard of PrEP before. From first-to-last steps included in the cascade, we found 77.3% (170/220) of participants were classified with HIV high risk, 75.9% (129/170) perceived themselves as being at high risk, 81.4% (105/129) expressed interest in using PrEP, 78.1% (82/105) were willing to do PrEP procedures, 48.8% (40/82) were willing to pay 500,000–600,000 IDR, and only two participants had ever been on PrEP before (5.0% of those willing to pay and 0.9% of the total sample). Multivariate logistic regression analysis showed that self-perception of high HIV risk was lower among older age groups (p < 0.001 among 30−39; p = 0.002 among > 40) and higher among participants with multiple sex partners (p = 0.016). Interest in using PrEP was lower among participants with high social engagement as MSM/waria (p = 0.002) and was higher among participants with multiple sex partners (p = 0.020) and inconsistent condom use (p = 0.011). This study has shown a significantly low level of PrEP awareness among its participants and decreases in interest in PrEP use due to procedure and cost. It suggested that an appropriate PrEP campaign is needed if PrEP is going to be introduced in Indonesia.

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

“…We also found that only 2.6% of anal intercourse events were protected by PrEP in either the respondent or their partner. This supports similar findings of very low PrEP use among MSM/waria in Bali [5], and Indonesia more broadly [24]. Due to this lower use of PrEP, CLAI protected by biomedical prevention was still a minority practice in our study.…”

“…Finally, in bivariate analysis, the degree of social connection respondents had to other MSM/waria was associated with lower potential HIV transmission risk. Higher social engagement has been associated with condom use, HIV testing, and PrEP in international research [20][21][22], as well as with greater interest in using PrEP among MSM/waria in Bali [5].…”

“…PrEP has had major impacts on sexual cultures, including changes in condom use, among MSM [25]. However, as PrEP is not widely available in Indonesia [5,26], usage is very low, and PrEP is unlikely to have yet had a large impact on sexual behaviour in Bali. Finally, as HIV testing was not conducted as part of this study, there was a relatively large proportion of participants with unknown HIV status.…”

“…The survey included items on: demographics; strength of identification with sexual identities (on a scale from 0 = not at all to 3 = very much); gender identity; HIV testing; ART, viral load and CD4 count in HIV-positive respondents; PrEP use in HIV-negative respondents; sex work in the previous 6 months (including sex in exchange for money or gifts, both incidental and as the main source of income); sexual behaviour in the last 6 months (sex with men, women, and/or waria); where respondents met male/waria sex partners in the last 6 months (mobile apps, social media, gay bar/club, other bar/club, gay sauna, and/or a public area); alcohol use, recreational drug use (including ecstasy, cannabis, crystal methamphetamine, cocaine, and/or heroin), and any drug use for the purposes of sex in the last 6 months; attitudinal items (belief in effectiveness of withdrawal before ejaculation to prevent HIV; how much the respondent likes using withdrawal and condoms); and a two-item scale on social engagement with MSM/waria (number of MSM/waria friends and amount of free time spent with them) [5], adapted from a reliable scale used in HIV research with gay and bisexual men [10].…”

“…For HIV-negative MSM/waria at high risk of infection, HIV pre-exposure prophylaxis (PrEP) is not available in Indonesia. Purchasing PrEP without a prescription is illegal and costly, and legally procuring PrEP pills from nearby countries such as Thailand is cost prohibitive for most potential PrEP users [5]. Previous work has demonstrated low awareness and use of PrEP among MSM in Bali, but relatively high interest in using it after being informed about it [5].…”