HIV risk behaviours and solutions among men who purchase sex in Indonesia

There has been a limited focus on HIV among men who purchase sex (MWPS) in many countries. Systematic information is lacking on the HIV prevalence in this population, and on interventions conducted to reduce HIV risk. Looking specifically to Indonesia, MWPS are understood to be at higher risk of HIV infection compared with men in the general population but there has been a relative lack of attention put towards identifying characteristics such as the rate of condom use and HIV testing in this population and developing appropriate interventions. Accordingly, the studies included in the thesis contribute to filling the knowledge gap for this population in regard to estimation of rate of condom use and HIV testing and evaluation of control strategies among MWPS in Indonesia. A range of research designs and analytical approaches was applied. The first study is a meta-analysis of the burden of HIV among MWPS in low- and middle-income countries (LMICs). We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association (RR 1.95) between purchasing sex and HIV prevalence. The second study is a systematic review of HIV interventions conducted among MWPS, or groups often used as proxies for MWPS, in LMICs to reduce their risk of HIV infection. We observed that only a few studies had evaluated the impact of interventions on HIV testing rates. The third study is a survey in Bali, Indonesia, which identifies rates and predictors of condom use and HIV testing among MWPS in this setting. The study found a high condom use (88.5%), but low HIV testing rates (8.1%) among this group. The fourth study explores in more detail why such a low HIV testing phenomenon among MWPS occurs in this setting and the preferences for testing strategies. Men‘s preference for HIV self-testing over HIV testing at the clinic was expressed. The fifth study is a study piloting the HIV self-testing strategies to identify whether this method could improve HIV testing rates among this group. A pilot single-arm non-randomised trial study was conducted among men presenting at the brothels area and found high acceptability of this testing strategy to improve HIV testing rates among MWPS; HIV testing acceptance was 6-7 times higher than the HIV testing history of less than 8.1% found in the third study. Together, the five studies provide insight into estimation of the HIV burden and evaluation of control strategies among MWPS in Indonesia.