High condom use but low HIV testing uptake reported by men who purchase sex in Bali, Indonesia

A qualitative study of healthcare providers' attitudes toward assisted partner notification for people with HIV in Indonesia

BACKGROUND

Assisted partner notification (APN) is recommended as a public health strategy to increase HIV testing in people exposed to HIV. Yet its adoption in many countries remains at an early stage. This qualitative study sought the opinions of HIV health service providers regarding the appropriateness and feasibility of implementing APN in Indonesia where such services are on the cusp of adoption.

METHODS

Four focus group discussions totaling 40 health service providers were held in Jakarta, Indonesia to consider APN as an innovative concept and to share their reactions regarding its potential implementation in Indonesia. Voice-recorded discussions were conducted in Bahasa, transcribed verbatim, and analyzed.

RESULTS

Participants recognized APN's potential in contacting and informing the partners of HIV-positive clients of possible viral exposure. They also perceived APN's value as a client-driven service permitting clients to select which of three partner notification methods would work best for them across differing partner relationships and settings. Nonetheless, participants also identified personal and health system challenges that could impede successful APN adoption including medical and human resource limitations, the need for specialized APN training, ethical and equity considerations, and lack of sufficient clarity concerning laws and government policies regulating 3^rd party disclosures. They also pointed to the job-overload, stress, personal discomfort, and the ethical uncertainty that providers might experience in delivering APN.

CONCLUSION

Overall, providers of HIV services embraced the concept of APN but forecast practical difficulties in key service areas where investments in resources and system change appeared necessary to ensure effective and equitable implementation.

HIV self-testing for men who have sex with men: an implementation trial in Indonesia

We investigated oral fluid testing (OFT) among men who have sex with men (MSM) to increase HIV testing in Bali, Indonesia. We distributed OFT in January-December 2018 to 813 MSM in Bali. Supervised testing was offered first, and unsupervised was only offered to an individual who declined supervised testing. Included participants were MSM who did not have a HIV test result in the last 6 months and declined referral to facility-based testing. Of 813 participants, 93% (765/813) chose supervised testing and 7% (57/813) unsupervised. The OFT result was reactive for 83 (10%), of whom 52/83 (63%) underwent confirmatory testing with 47/52 (90%) found HIV positive. Among confirmed positives, 43/47 (92%) were enrolled in HATI study cohort, of whom 39 (91%) started treatment. At six months follow up, 25/39 (64%) of those initiating treatment were still receiving it, and all had a suppressed viral load. There was an increase in the mean number of MSM tested for HIV by HATI study Bali sites per month, from 100 (95%CI: 85-112) before the intervention to 152 (95% CI: 130-172) during the intervention. Our findings show the potential utility of offering HIV oral fluid self-test kits to scale-up HIV testing in MSM.Trial registration: ClinicalTrials.gov identifier: NCT03429842.

Perspectives on voluntary assisted partner notification among providers, people with HIV and the general population in Indonesia: a formative qualitative study

BACKGROUND

Voluntary assisted partner notification (aPN) services are effective in increasing access to and uptake of HIV testing among partners of people with HIV. Following recommendations by the World Health Organization in 2016, Indonesia evaluated various approaches to aPN. We present the lessons learned from formative operational research undertaken to understand provider and patient perspectives on aPN from three demonstration sites in cities with a high HIV burden.

METHODS

We conducted a formative qualitative study in three cities: Jakarta, Semarang, and Denpasar between September and October 2019. We conducted six focus group discussions (FGDs) (n = 44 participants) among health-care providers, people living with HIV and the general population. We explored participant preferences and concerns about how aPN should be delivered, including the methods of and messaging for contacting partners. All FGDs were conducted in the Indonesian language. Qualitative data were analysed using thematic analysis.

RESULTS

aPN was acceptable across different participant populations, although with caveats. Some differences were observed between the general population, providers and people living with HIV. People living with HIV were mainly concerned with confidentiality of the procedure and preferred the use of telecommunication and messages that avoid explicit mention of HIV exposure. Providers preferred similar approaches but for different reasons, being concerned mainly with self-efficacy and security. There was consensus regarding dual referral models. The use of phone calls and short messages were preferred as these are perceived to minimize negative reactions and stigma, protect client confidentiality and are suitable in the current legal situation. The general population was mainly concerned with effectiveness and prefer direct provider-led approaches, such as preferring in-person meeting with explicit notification of potential HIV exposure.

CONCLUSIONS

We found consensus among stakeholders on acceptance of aPN, especially dual referral methods. Development and implementation of aPN protocols should also consider clients' individual situations and concerns regarding safeguarding of confidentiality, and offer a range of options to accommodate all stakeholders involved.

The roles of women empowerment on attitude for safer sex negotiation among Indonesian married women

The situation of low women empowerment in household settings might influence women's attitude and ability to negotiate for protected sex in their marital relationship. This study aimed to investigate the association between women empowerment factors and the attitude for safer sex negotiation among Indonesian married women. The secondary data of 28,934 individual records of married women retrieved from the 2017 Indonesia Demographic and Health Survey (IDHS) was used. The dependent variable was the attitude for safer sex negotiation measured by women's acceptance toward a justification to ask her husband to use a condom if her husband has a sexually transmitted disease. Multivariate logistic regression analysis accounting for the complex survey design was performed. The results showed that women empowerment factors, that include higher level of education and participation in household decision-making had a positive effect on women's attitude for protected sex. Those women with higher levels of HIV knowledge and whoever talked about HIV with their husbands were also more likely to justify for protected sex. Therefore, women empowerment through education, improving socioeconomic conditions, and increasing HIV-related knowledge can help develop a positive attitude and enable women to negotiate for safer sex with their partners.

The burden of HIV infection among men who purchase sex in low- and middle-income countries - a systematic review and meta-analysis

Background

Since the start of the HIV epidemic, transactional sexual relationships have been considered to present a high risk of HIV transmission to both the client and the person offering the sexual service. However, prevention research and programs have focused predominantly on sex workers rather than on their clients, who are generally men. To support effective and targeted interventions, we undertook a systematic review and meta-analysis of the evidence of the prevalence of HIV infection among men who purchase sex (MWPS) in low- and middle-income countries (LMICs), and the association between HIV infection and purchase of sex.

Methods

We included articles that reported from LMICs on the prevalence of HIV in MWPS and those that reported on HIV prevalence among both MWPS and non-MWPS in the same study, or any information which allowed calculation of the prevalence. We defined MWPS as heterosexual males (not men who purchase sex or individuals of other sexual orientation) who purchased sex mostly from women (and not men), or who have had sexual contact with female sex workers (FSWs). We searched Medline, Global Health, Scopus, Embase and Cinahl for articles published up until 1 March 2020. Meta-analysis was conducted using a random effects model to estimate the pooled HIV prevalence and the relative risk (RR) of HIV infection associated with purchasing sex.

Results

Of 34862 studies screened, we included 44 studies (59515 men, 47753 MWPS) from 21 countries. The pooled HIV prevalence among MWPS was 5% (95%CI: 4%-6%; I² = 95.9%, p < 0.001). The pooled HIV prevalence calculated from studies that reported data collected pre-2001 was highest, i.e. 10% (95% CI: 6%-14%; I² = 91.2%, p < 0.001), compared to studies whose data was collected between 2001–2010, i.e. 4% (95%CI: 2%-6%; I² = 96.6%, p < 0.001), and from 2011 and beyond, i.e. 3% (95% CI: 2%-5%; I² = 94.3%, p < 0.001). For studies which included comparisons of HIV infection among MWPS and non-MWPS, the relative risk of HIV infection was consistently higher among MWPS than among non-MWPS within the same study, with the overall pooled relative risk of 1.95 (95%CI: 1.56–2.44; I² = 84.3%, p < 0.001), and 2.85 (95%CI: 1.04–7.76; I² = 86.5%, p < 0.001) for more recent studies.

Conclusions

This review represents the first comprehensive assessment of the burden of HIV among MWPS in LMICs. We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association between purchasing sex and HIV prevalence. Despite a reduction over time in prevalence, these data highlight that MWPS need better access to HIV preventive interventions.

Exploring the acceptability of HIV partner notification in prisons: Findings from a survey of incarcerated people living with HIV in Indonesia

Assisted HIV partner notification services provide a safe and effective way for people living with HIV (PLHIV) to inform their partners about the possibility of exposure and to offer them testing, treatment, and support. This study examined whether or not PLHIV in prison might be willing to participate in assisted HIV partner notification services and their reasons for and against disclosing their HIV-positive status to their partners. PLHIV (n = 150) recruited from Jakarta's two largest all-male prisons completed an interviewer-administered questionnaire collecting demographic and risk behavior data, and attitudes toward HIV disclosure and partner services. Among those who were sexually active and/or injecting drugs before incarceration, two-thirds (66.4%, 91/137) endorsed provider referral as an acceptable way to notify their sex partners, and nearly three quarters (72.4%, 89/123) endorsed provider referral to notify their drug-injecting partners. Only a quarter (25.1%) of participants reported that their main sex partner had ever received an HIV test. Participants with anticipated stigma were less likely to endorse provider referral for sex partners (adjusted odds ratio [aOR] = 0.58, 95% CI: 0.35, 0.96) and drug-injecting partners (aOR = 0.54, 95% CI: 0.29, 1.00). Relationship closeness was associated with higher odds of endorsing provider referral for drug-injecting partners (aOR = 2.08, 95% CI: 1.25, 3.45). Protecting partners from infection and a moral duty to inform were main reasons to disclose, while stigma and privacy concerns were main reasons not to disclose. Most incarcerated PLHIV have at-risk partners in the community who they would be willing to notify if provided with assistance. Assisted partner notification for prison populations offers a promising public health approach to accelerate diagnosis, treatment, and prevention of HIV infection in the community, particularly among women.

Prevalence of and factors associated with behavioral intention to take up home-based HIV self-testing among male clients of female sex workers in China - an application of the Theory of Planned Behavior

ABSTRACTHIV self-testing (HIVST) is a useful means to increase coverage of HIV testing but under-utilized by male clients of female sex workers (MCFSW) in China. This study investigated the prevalence of and factors associated with behavioral intention to take up HIVST in the next year among MCFSW in Hong Kong, China. We recruited Chinse-speaking adult men who had patronized at least one female sex worker in the past six months. A total of 303 MCFSW completed a self-administered questionnaire. Univariate and multivariable ordinal logistic regression models were fit. Only 23.8% of participants indicated that they probably/definitely would take up HIVST in the next year. The multivariable ordinal logistic regression model showed that positive attitudes towards HIVST (adjusted odds ratios (aOR): 1.24, 95%CI: 1.13, 1.37), perceived HIVST uptake is completely under one's control (perceived behavioral control) (aOR: 1.44, 95%CI: 1.08, 1.92), and perceived higher risk of HIV infection (aOR: 1.32, 95%CI: 1.01, 1.76) were associated with higher intention to take up HIVST in the next year. The prevalence of behavioral intention to use HIVST was low among MCFSW in Hong Kong. Perceptions based on the Theory of Planned Behavior and perceived risk of HIV infection were associated with behavioral intention to use HIVST.

Female sex workers perspectives and concerns regarding HIV self-testing: an exploratory study in Tanzania

BACKGROUND

HIV testing is a gateway to HIV care and treatment for people diagnosed with HIV and can link those with negative results to HIV preventive services. Despite the importance of HIV testing services (HTS) in HIV control, uptake of HTS among female sex workers (FSWs) across sub-Saharan Africa (SSA) remains sub-optimal. Concerns about stigma associated with sex work and fear of loss of livelihood if HIV status becomes known, are some of the restrictions for FSWs to utilize HTS offered through health care facilities. Introduction of HIV self-testing (HIVST) may mitigate some of the barriers for the uptake of HTS. This study explored the acceptability of FSWs towards the introduction of HIVST in Tanzania.

METHODS

We conducted an exploratory study employing in-depth interviews (IDI) and participatory group discussions (PGD) with FSWs in selected regions of Tanzania. Study participants were recruited through snowball sampling. Data were thematically analysed by two analysts using NVivo software. The analysis was informed by the social-ecological model and focused on factors associated with the acceptability of HIVST.

RESULTS

We conducted 21 PGD sessions involving 227 FSWs. Twenty three IDIs were conducted to complement data collected through PGD. Our study has demonstrated that FSWs are enthusiastic toward HIVST. Convenience (time and cost saved), and belief that HIVST will increase privacy and confidentiality motivated participants' support for the self-testing approach. Participants did express concerns about their ability to interpret and trust the results of the test. Participants also expressed concern that HIVST could cause personal harm, including severe distress and self-harm for individuals with a reactive test. Very likely, concern about adverse effects of HIVST was linked to the study participants' lay perception that HIVST would be provided only through unassisted modality.

CONCLUSIONS

FSWs demonstrated high enthusiasm to use the HIVST once it becomes available. Expectations for increased confidentiality, autonomy, and reduced opportunity costs were among the leading factors that attracted FSWs to HIVST. The major obstacles to the acceptability of HIVST included fear of HIV reactive test and not trusting self-diagnoses. Our findings underscore the importance of providing adequate access to counselling and referral services in conjunction with HIVST.

Uptake and acceptability of assisted and unassisted HIV self-testing among men who purchase sex in brothels in Indonesia: a pilot intervention study

Background

Along with sexual partners of other high-risk groups, men who purchase sex (MWPS) represented 18% of new HIV diagnoses worldwide in 2018. They are therefore an important population for HIV prevention globally. Despite very low HIV testing coverage among MWPS in many countries, the role of HIV self-testing to increase testing coverage has not been explored. We, therefore, conducted a pilot intervention study to evaluate the uptake and acceptability of assisted and unassisted HIV self-testing among MWPS in Indonesia.

Methods

MWPS attending seven brothels in Bali between December 2017 and January 2018 were recruited by lay health providers to participate in a brief health survey, and then invited to have a HIV self-test (assisted or unassisted) with an OraQuick® ADVANCE Rapid HIV-1/2 Antibody Test and complete a post-test acceptability survey.

Results

A total of 292 men completed the health survey (response rate: 70%) and 188 (64.6%) accepted HIV self-testing. Of these men, 13.3% had ever tested for HIV and 58.9% reported condom use at their last sexual encounter with a brothel-based female sex worker. Nearly all men (98.9%) who accepted a HIV self-test preferred assisted HIV self-testing – of whom 83.9% preferred to be fully assisted and 16.1% opted to be partially assisted and read their results privately. Of the men who accepted the test and showed the result to the lay health providers, 4 (2.1%) received reactive results. Linkage following HIV self-test is a concern, as none of the four men with a reactive result attended HIV testing at the recommended referral HIV testing clinic over a two-month follow-up period.

Conclusions

This study is the first to investigate the acceptance of HIV self-testing when offered to MWPS in brothels by lay health providers. The high uptake of HIV self-testing suggests that this testing model is acceptable and could increase the very low HIV testing coverage among MWPS. The strong preference for fully assisted HIV self-testing highlights the importance of involving lay health providers in future testing programs. When scaling up HIV self-testing programmatically, strategies to improve linkage-to-care should be considered and evaluated.

"Self-testing sounds more private, rather than going to the clinic and everybody will find out": Facilitators and barriers regarding HIV testing among men who purchase sex in Bali, Indonesia

In many Asian countries, men who purchase sex account for the largest single network of people which often face elevated HIV risk in relation to the general population. However, high proportions of these men have never undertaken HIV testing. We assessed barriers to and facilitators of HIV testing among men who purchase sex in Indonesia, including the acceptability of HIV self-testing. A qualitative study was conducted during December 2016-January 2017 at fourteen sex-work venues and one voluntary HIV counselling and testing (VCT) clinic in Bali. Interviews were conducted with men who purchase sex exploring the men's views on HIV testing. Data were examined using thematic analysis. Twenty-nine men participated in the study. The themes that emerged regarding the barriers to HIV testing included fear of potential shame, embarrassment, and confidentiality breach in accessing HIV testing; fear of social exclusion if the test result was positive; self-treatment and prevention; the distance to a clinic; time constraints; and fear of an invasive testing method. Factors that were seen as facilitating a test were the convenience of time and place; the provision of speedy results; and privacy. Participants expressed interest in HIV self-testing and preferred it to clinic-based testing due to the privacy and confidentiality of the results. The findings support the introduction of an HIV self-testing strategy among this group to improve access to HIV testing.