This document presents valuable data about HIV/AIDS-related knowledge, attitudes, and behaviors, based on specialized behavioral surveillance surveys conducted among high-risk populations in Indonesia from 1996 to 2000.

Introduction

The growing number of HIV/AIDS cases in Indonesia has challenged policy makers to take urgent steps to implement the National AIDS Strategy. Many people within Indonesian government agencies and the public at large are now active, both independently and jointly, in efforts against the epidemic. In the continued absence of vaccines and effective, affordable drugs for preventing or treating HIV infection, the government promotes culturally and religiously appropriate educational efforts aimed at promoting abstinence, encouraging people to have fewer sex partners, and increasing the use of condoms.

Between 1996 and 2000 the Indonesian government collaborated with Family Health International (FHI), USAID, and non-governmental organizations in seaport cities of Indonesia (notably, North Jakarta, Surabaya, and Manado) to implement the HIV/AIDS Prevention Project (HAPP). HAPP promoted behavior change, policy reform, improved STD diagnostic and treatment services, and increased access to condoms for those at greatest risk of infection. The Behavioral Surveillance Surveys (BSS) funded by HAPP, which have been carried out since 1996, serve as a tool to help measure the changes in behaviour which may result from HAPP together with other HIV prevention interventions. It is important to note that observed trends cannot be attributed to any single intervention. Rather, they serve to indicate what risk behaviors are present in the geographic areas where groups are sampled. Individuals may or may not be exposed to any number of interventions.

The BSS

Behavioral surveillance surveys (BSS) form an important component of integrated surveillance systems for monitoring the HIV epidemic and are included in the 2^nd generation surveillance systems recommended by UNAIDS and WHO. The BSS methodology is a monitoring and evaluation tool designed to track trends in HIV/AIDS-related knowledge, attitudes, and behaviors in sub-populations at particular risk of HIV infection, such as female sex workers, injection drug users, migrant men, and youth. However, groups included in a BSS depend on the state of the epidemic and the distribution of risk in populations.

The BSS consist of repeated cross-sectional surveys conducted systematically to monitor changes in HIV/STD risk behaviors. 1 A key benefit of the methodology is its standardized approach to questionnaire development, sampling frame construction, and survey implementation and analysis. BSS findings serve many purposes: They can help identify appropriate intervention priority populations, identify specific behaviors in need of change, provide indicators of success of prevention efforts and highlight persistent problem areas, function as a policy and advocacy tool, and, to a more limited extent, supply comparative data concerning behavioral risks.2

This report highlights findings from female sex workers and adult males (specifically sailors and seaport workers and truckers and their assistants) from the first through the fifth waves of the BSS, conducted yearly in 1996, 1997, 1998, 1999, and 2000.

Study Design and Methodology

All waves of the BSS, from the initial wave in 1996 through 2000, followed the same methodology, described below.

Study population

The BSS were designed to enable measurement of behavior change over time among specific sub-populations. Data on high-risk groups provide valuable information on the segments of the population having the greatest impact on the HIV and STD epidemics. Therefore, many of the groups included in the BSS were those at highest risk of infection and transmission, such as female sex workers.

Table 1: Sub-population Definitions for BSS 2000

Category	Description	Location
Brothel-complex based sex workers ("Lokalisasi-based" LSWs)	Women selling sex for money	Mostly located in a formalized setting for commercial sex, such as a brothel complexes (localization areas)
Other sex workers ("Non-lokalisasi based" NLSWs)	Women selling sex for money	Mostly located in an informal setting, such as a street, bar/pubs or discotheques
Sailors and Seaport workers/ laborers (S/SLs)	Ships crew/ sailors and seaport workers and laborers	Mostly located in main sea-ports or harbors esp. during docking.
Truckers (TD/As)	Inter-provincial truck drivers and drivers' assistants	Mostly located in regular inter-province truck pools

In addition to sex workers, sailors/seaport laborers (S/SLs), and truck drivers and their assistants (TD/As) were included in the surveys. These groups of men who have ready cash and are employed in mobile occupations which frequently take them away from home are know to be frequent clients of sex workers. Many of them are also married or have regular non-commercial sex partners, so they act as potential "bridges", able both to carry infection from one part of the country to another and to carry it from populations with high risk behaviour into populations with lower risk behaviour. 3

Study sites

The HAPP intervention sites of North Jakarta, Surabaya, and Manado were selected as the sites for the BSS. Besides being major entry ports for the country, these three cities have cosmopolitan and urban characteristics, with active sex industries. The study sites with the corresponding sub-populations for wave one through five is as follows:

Table 2: Survey Populations with Study Sites and Sample Sizes, BSS 1996-2000. Click here to view table.

Sample size and design

Sample size calculations are extremely important in behavioral surveillance. Sample sizes were determined for each group and in each city on the basis of behavioral parameters, the behavior change to be detected, the degree of confidence in such a change, statistical power and design effects. Sample sizes were increased in the year 2000 wave to yield more precise estimates. A two-stage cluster design was employed with each group. During the first stage, clusters were selected by probability proportional to size from a complete list of sites. Respondents were selected from the selected clusters during the second stage.

A sampling frame was initially prepared to provide the basis for selecting clusters. Brothel complexes were used as clusters for Brothel complex-based sex workers while areas such as brothel houses, streets, massage houses, hotels, and discotheques, bars, and nightclubs were used for other sex worker clusters. Seaport areas were used as clusters for sampling sailors and seaport laborers, and truck pool areas were used for locating truckers and assistants. Information regarding clusters, such as city, population group, geography, and the estimated number of individuals per cluster, was recorded.

The questionnaires were developed in stages parallel to the field preparation. Separate questionnaires were developed for sex workers and male respondents based on international best practices. 4

Demographic characteristics

Most of the adult male respondents were age 20 or above. In 2000, about 47% of the male respondents were aged between 20-29 years old, and another 50% were aged 30 years old or above. Just four percent were in their teens.

In terms of their educational background, about 45% had completed senior high school education or above. There seems to be more respondents each year that completed senior high school or tertiary education. In general, sailors tend to have better education than truckers.

Nearly two thirds of the adult male respondents were currently married, while almost all of the rest had never been married. (For complete details see annex Table AMB1)

The age pattern among the sex workers was rather different. There were many who were still in their teenage years (about 14% who were aged 20 years or under in 2000, compared with 12% in 1996). In 2000 more than half of all sex workers surveyed were aged between 20-29 years old, with another third aged 30 years or above.

The level of education remains low among sex workers over the years. However, the number of sex workers who reported finished junior high or senior high seems to be increasing over the years. In 2000, almost half of the respondents reported finish junior or senior high school levels. The remainder only completed primary level or had no education at all. Sex workers working outside brothel complexes tend to indicate better education levels compared to their counterparts in brothel complexes.

Acknowledgment

The first baseline STD/HIV Risk Behavioral Surveillance Survey (BSS) was conducted by the Center for Health Research University of Indonesia (CHR-UI) in late-1996 on behalf of the DepKes RI, Directorate General of Communicable Disease Control and Environmental Health (Ditjen P2MPLP) under the HIV/AIDS Prevention Project (HAPP). This was subsequently continued with a second BSS in 1997. As a follow up to the successful outcome of BSS 1996 and 1997, and the continued need to generate comparative time-series data, the third and fourth rounds of BSS were implemented by mid-1998 and 1999. This report on BSS 2000 data, and its comparison with the results of BSS 1996, 1997, 1998, and 1999 was made possible because of the active participation of government related agencies, most notably the Ministry of Health, and NGOs at the central and provincial levels. The financial support for all these BSS were provided by USAID through the Family Health International.

First and foremost, the CHR-UI would like to extend its gratitude to all respondents and field personnel who have participated in the survey. The CHR-UI would like also to acknowledge many institutions and individuals who have provided administrative and operational support for the BSS 2000 in North Jakarta, Surabaya, and Manado. Appreciation is extended to the Ministry of Health, the Ministry of Social Affairs, the Ministry of Internal Affairs, the Ministry of Education and Culture, the Ministry of Transportation, the Ministry of Labor Force, the Ministry of Tourism, Post and Telecommunication, BKKBN, the Ministry of Religion, Bappenas, Bappeda, the Office of the Minister Coordinator of People's Welfare, and the related NGOs in Jakarta, Surabaya and Manado. We thank the NGOs, Hotline Surya and Abdi Asih, for their help in facilitating data collection from commercial sex workers in Surabaya and Dr. Bambang S. Resident HAPP Officer, Surabaya, Dr. Yoppie Manoy and Dra. Sri Hardianti Gunadi, HAPP officers in Manado. The support of Forkom Waria, Jakarta, in connecting with transvestites is also acknowledged, as well as those individual gate-keepers in Jakarta who connected us with IVDUs.

Many thanks are extended to those individuals who have made possible the smooth flow of the BSS 2000 field operations. Most notably to the Director General, P2MPLP, Ministry of Health. Thanks also to Dr. James C. Sonnemann, Country Director-FHI Indonesia who supported the continuation of BSS-V. Thanks are also due to Dr. Arwati Soepanto (Project Manager, HAPP), Ms. Jane Wilson (Chief of Party under the original HAPP), and Mrs. Diah (Program Officer, HAPP) for their administrative support. Dr. John Moran and Mr. Steve Mills also provided support throughout the operations. Our appreciation is also extended to the various government agencies supporting the BSS activities, namely the Office of Secretary General, Ministry of Internal Affairs, the Office of Secretary General, Ministry of Education and Culture, General Bureau Head, Ministry of Tourism, Post and Telecommunication, General Bureau Head, Ministry of Transportation, the Office of Secretary General, Ministry of Social Affairs, the Faculty of Medicine, University of Sam Ratulangi, and the Office of Secretary General, Ministry of Labor Force.

The report was prepared by Dr. Nick G. Dharmaputra and Prof. Budi Utomo. The data collection and analysis which form the basis of this report could not be possible without the diligence of field managers: Drs. Heru Suparno who coordinated operations in Jakarta, Drs. Dadun in Manado, and Drs. Subarkah in who coordinated operations in Surabaya. They were all supported by many CHR-UI research staff, most notably, Drs. Amri Ismail and Drs. Ferdinand Siagian during both the pre and post field work activities.