Condom-use negotiation, alcohol consumption, and HIV-risk sexual behavior among female sex workers in Kupang, East Nusa Tenggara, Indonesia: A cross-sectional study.

BACKGROUND: Female sex workers play a crucial part in HIV transmission. Having unprotective condom during sexual activity can lead to HIV infection. Having lower power in condom negotiation with clients can lead  FSW not to using condoms during sexual activity. Alcohol consumption was also mediated HIV risk behavior among FSW. This study aimed to evaluate the relationship between condom use-negotiation, alcohol consumption and HIV-risk sexual behavior among female sex workers (FSW) in Kupang. DESIGN AND METHODS: A cross-sectional study was conducted with 125 FSWs aged 18 to 60 years recruited from Yayasan Tanpa Batas Kupang with consecutive sampling. The data were analyzed using univariate and the Chi-square test.
RESULTS: The majority of FSWs (61.6%) reported had low negotiation condom use with their clients, about 77.6% reported high levels of alcohol consumption and 64.8% had high-risk sexual behavior. Condom-use negotiation (p-value: 0.003) and alcohol consumption (p-value: 0.037) were found to be significantly associated with HIV-risk sexual behavior.
CONCLUSIONS: Future interventions on HIV prevention should focus on empowering young FSWs with condom negotiation skills in order to increase condom use. It is also recommended to include information about alcohol consumption and its relationship with HIV-risk behavior in order to have better health outcomes for FSW.

Introduction

Human Immunodeficiency Virus (HIV) is a major global health issue. Data from The Joint United Nations Programme On HIV and AIDS (UNAIDS) reported that people living with HIV/AIDS had reached more than 36.7 million people in 2016 with the main route of transmission through sex among heterosexuals.

Significance for public health

HIV-risk sexual behavior among Female Sex Workers (FSW) is significant for public health. FSW may become of the key population of the high transmission of HIV in FSWs and their clients is caused by HIV-risk sexual behavior. Condom-use negotiation, alcohol consumption may influence HIV-risk behavior among female sex workers, particularly in Kupang, Indonesia. Therefore, increasing ability of FSW to have good negotiation with clients. FSWs abilities to negotiate condom used by involving peers, and reduce alcohol consumption. In addition, routine counseling, education, and positive support from health workers, such as nurses, is needed to decrease HIV-risk sexual behavior among FSW.

Based on Directorate General of Disease Prevention and Control, the number of new cases in Indonesia from January to March 2017 was 10,376 people and the highest risk factor for HIV transmission was heterosexual sexual intercourse. Kupang is one of the regions in Indonesia with increased the numbers of HIV cases. Based on data from January to December 2016, there were 235 new HIV cases in Kupang. In 2017, new cases increased to 242 with the top risk factor from sexual intercourse (heterosexual). Female sex workers plays crucial part in HIV transmission. Having unprotective condom during sexual activity can lead to HIV infection. Having lower power in condom negotiation with client can lead FSW not to using condoms during sexual act.[6,7] One of the high-risk sexual behaviors for HIV AIDS transmission is sex without a protection (condom). The high transmission of HIV and sexually transmitted diseases in FSWs is caused by the low negotiation on condom use, which affect the inconsistencies in the use of condoms.

The ability to negotiate condom use among FSW is a contributing factor in offering clients safe sex. However, when FSW does not have the ability to negotiate condom use, it makes it easier to have unsafe sex. Prior research revealed that FSW who did not negotiate or did not have a good ability to negotiate safe sex reported inconsistent using condom with their clients.

Alcohol consumption was also mediated HIV risk behavior among FSW. Based on some previous studies, excessive alcohol consumption tends to increase the decision to participate in risky sexual behavior, especially in the form of unsafe sex. Berry and Johnson revealed that alcohol use leads to an increase in the possibility of having unprotected sex.

Knowing the risky sexual behavior of female sex workers and their relationship to the negotiation skills of condom use and alcohol consumption is essential to determine appropriate interventions. This study aimed to evaluate relationship between condom-use negotiation, alcohol consumption and HIV-risk sexual behavior among FSWs.

Design and Methods

Study design

This study used observational research design with cross sectional design.

Setting and respondents

This study was conducted from February, 2019, to March 2019 at one of NGO, Yayasan Tanpa Batas, in Kupang, East Nusa Tenggara Indonesia. This NGO provided several information and service for people with HIV, such as information about HIV/AIDS, reproductive health and also several issues related with HIV in Kupang.

Sample

The potential respondents were recruited by staff NGO, Yayasan Tanpa Batas Kupang using consecutive sampling. we carried out self-administered questionnaires survey of 125 FSW in Kupang, Province of East Nusa Tenggara.

The survey had three section. The first section asked questions about demographic variables: age, education, income, and marital status. The second section comprised question about HIV-risk sexual behavior, using the safe sexual behavior questionnaire (SSBQ) which consists of 24 items. The items are answered on a 4 likert scale ranging from 1 (never) to (very often). The third section about Condom-use negotiation was measured by the Condom Influence Strategy Questionnaire (CISQ), which consists of 7 items. The items are answered on a 4 likert scale ranging from 1 (never) to (very often). Alcohol consumption was measured by the Alcohol Use Disorders Identification Test (AUDIT) consisting of 10 items. All instruments have been tested for validity and reliability. SSBQ values were determined as reliable with Cronbach's alpha (0,77), CISQ (0,820) and AUDIT (0,913). All respondents were informed that their participation is voluntary and guaranteed the privacy of the data. Once respondents agree to participate.

Ethical consideration

Ethics approval from The Ethics Committee of Faculy of Nursing Universitas Indonesia was obtained for this study (No.11/UN2.F12.D/HKP.02.04/2019).

Data analysis

Descriptive analysis was used to describe demographic characteristics (e.g age, educational level, income, marital status, risky sexual behavior, condom use negotiation and alcohol consumption. Bivariate analysis, chi-square test to measure the relationship between dependent and independent variable.

Results

Table 1 shows the majority of respondents were aged 18-40 years (88.8%), had low educational levels (51.2%), had high income (73.6%), were unmarried (61.6), had low levels of condom-use negotiation (61.6%), consumed high levels of alcohol (77.6%) and had sexual behavior at high risk of HIV (64.8%).

Table 1.

Characteristics of respondents (n = 155).

Characteristics	f	%
Age (year)
18-40	111	88.8
41-60	14	11.2
Education
Low	64	51.2
High	61	48.8
Income
Low	33	26.4
High	92	73.6
Marital status
Unmaried	77	61.6
Merried	30	24
Widowed	18	14.4
Condom use negotiation
Low	77	61.6
High	48	38.4
Alcohol consumption
Low level	28	22.4
High level	97	77.6
HIV-risk sexual behavior
Low risk	44	35.2
High risk	84	64.8

The bivariate analysis shows that condom-use negotiation and alcohol consumption were significantly associated with risky sexual behavior (Table 2). We found that condom-use negotiation was positively associated with risky sexual behavior (p-value: 0.003, OR: 3.318). Respondents who had low condom-use negotiation skill were 3,318 times to have high-risk sexual behavior than those with high condom-use negotiation. The bivariate analisys also show that alcohol consumption was positively associated with risky sexual behavior (p-value: 0.037, OR: 2.706). Respondents who had high level of alcohol consumption were 2.706 times to have high-risk sexual behavior than those with low level alcohol consumption.

Table 2.

Relationship between condom-use negotiation and alcohol consumption toward HIV-risk sexual behavior (n = 155).

	Risky Sexual Behavior				OR	P-Value
Variable	Low risk		High risk
	N	%	N	%
Condom use negotiation
High	25	52.1	23	47.9	3.3	0.003*
Low	19	24.7	58	75.3
Alcohol consumption
High level	15	53.6	13	46.4	2.7	0.037*
Low level	29	29.9	68	70.1

level of significant : <0,05

Discussion

The majority of respondents had low negotiation skills (61.6%) and among 75.3% of respondents with low negotiation skills had high-risk sexual behaviors. According to Exavery et al., 2012, condom-negotiation skills effect the use condoms during sex. Individuals with low condom-negotioation skills experience inconsistent use of condoms. The negative impact of low condom-negotiation skill and high-risk sexual behavior is the increased transmission of HIV and sexually transmitted diseases in FSWs and their clients. Statistically, there was a significant relationship between the negotiation of condom use and HIV-risk sexual behavior among FSWs. This is also supported by several previous studies showed the skill of negotiating condom use was a significant factor in risky sexual behavior among FSWs.[12,13]

Study by Afiyanti and Solberg in Indonesia, women still have lower power in their relationship, particularly related with condom use. Condoms are still taboo, and women feel “ashamed” to their use, although with their husbands. Women accept their roles as a mothers and good housewife, who does not argue with their husbands, particularly about condom use for men. For FSWs, they have less power to negotiate condom use with their clients. Several studies in Indonesia showed lower rates of condom use among FSWs.[16-18] For example, a study by Basuki about FSWs in Jakarta show that Only 5.8% of sex workers consistently used condoms for a two-week period of observation. The main reason that they did not use condom because the beliefs that boyfriends, native indonesians and healthy-looking clients can not spread STDs. Another reason stated was that sex workers had already taken other preventive measures, like taking antibiotics before having sex.

Research conducted by Bui et al. in Cambodia revealed that FSWs who did not negotiate or did not have good skills in safe sex were 4.6 times less likely to use condoms with their clients. Other research by Exavery et al. showed that respondents who are confident in negotiating condom use with their sex partners are 3.1 times more efficient in using condoms compared with women who do not have confidence in negotiating condom use. Similiar study in Indonesia conducted by Irmayati, Yona, Waluyo among women in Indonesia revealed that 56,7% have unsafe sex behavior. One contributing factor is weak negotiation skill related their partner's condom use and lack of knowledge about HIV/AIDS.

Good negotiation skills will increase effective communication regarding condom use, and make it easier for FSWs to persuade clients to practice safe sex. Negotiation before sex will increase FSWs’ persuasive efforts to convince clients to have safe sex by reaching an agrement throught joint decision-making. Conversely, a lack of negotiation skills makes FSWs accept client demands for unprotected sex. Lack of condom negotiations can affect consistent of condom use.

Economic is the main contributing factor for FSWs’ risky sexual behavior in Kupang. Low economic status and the higher costs of living encourage FSWs to accept clients’ offers for unprotected sex.[18,24] Previous research conducted by Januraga in Bali Indonesia found two main logics for not using condom: economic reason and romantic relationships over condom use. Feeling secure and trust their clients is the underline reason for these FSWs did not use condom in Bali.

The study also revealed that 77.6% of FSWs had high levels of alcohol consumption. Similar research revealed that around 70% of FSWs reported consuming alcohol at high level. Consuming alcohol at high level affects sexual behaviors, including sex without condoms.

The high level of alcohol consumption among FSWs is caused by several factors. Most of them report that clients generally force them to use alcohol; bar or cabaret managers also demand they drink. In addition, some FSWs become dependent on alcohol consumption, and they need to purchase alcohol can cause them to accept client demands for unprotected sex.

Study results found a significant relationship between alcohol consumption and HIV-risk sexual behavior among FSWs. Some previous studies support these results. Other research conducted that consuming alcohol was significantly associated with the incidence of sexually transmitted diseases and unprotected sexual behavior. FSWs with high AUDIT scores tend to have unprotected sex with their clients compared to FSWs with low AUDIT scores.

Alcohol use before and during sexual intercourse is associated with damage to the behavioral abilities needed to negotiate condom use. Alcohol use can cause a decrease in the desire to use condoms, lower ability to remember to use them, and decrease and the capability to use them properly. In addition, sexual intercourse under the influence of alcohol can reduce self-control of sexual behaviors, leading to impulsive and risky sexual behavior.

Study conducted by Safika showed that alcohol consumption among FSWs in Indonesia is caused by the invitation and demands from clients. This situation led sexual behavior under influence of alcohol. Similiar to study in Tanzania, clients usually buy alcohol for FSWs to indicate they are interested in getting sexual services. Cultural factors in Kupang that include consuming traditional drinks (sopi) have a major influence on HIV-high risk transmission through sexual intercourse. The absence of regulations to restrict consumption of traditional alcoholic drinks in Kupang also contributed to the increase of alcohol consumption among FSWs and their clients. As a result, health promotion programs that highlight the negative effect of alcohol consumption among FSWs and their clients should be routine and continuous.

Conclusions

Based on study results, it was found that low condom-use negotiation and high level of alcohol consumption can affect HIVrisk sexual behavior among FSWs. Therefore, it is necessary to prioritize interventions that increase FSWs abilities to negotiate condom used by involving peers, and reduce alcohol consumption. It is essential to include level of non harm alcohol consumption in education material for FSWs before serving their clients. This is as one way to reduce the risky sexual behaviors of FSW. In addition, routine counseling, education, and positive support from health workers, such as nurses, is needed to decrease FSWs high risk sexual behaviors.