Presented by Nurlan Silitonga ASHM Conference, Cairns, 23 October 2003

1. Baseline prevalence and risk factors associated for STIs among newly-arrived female sex workers in Timika, Indonesia Silitonga N, Donegan E, Davies SC, Kaldor J, Wignall FS, Okoseray M, Schachter J Presented byNurlan SilitongaASHM Conference, Cairns, 23 October 2003

2. Acknowledgements • Mimika District Health Office • PT Freeport Indonesia • International SOS • University of California, San Francisco • Naval Medical Research Unit No 2 • Sexually Transmitted Infectious Research Centre – University of Sydney • University of New South Wales • Ford Foundation

3. Indonesia • 39 active mining companies (30,000 miners). • The mines are mostly in remote locations, employ male workers • An increasing number of FSWs has become available for these men • Most of the women are poor and illiterate. Little information on STIs and often have little negotiating power for condom use

4. HIV/AIDS and STIs in Indonesia • The HIV/AIDS program primarily in urban areas and focuses on HIV testing • Diagnosis and treatment of STIs are rarely available • Many people do self-treated • Inadequate STI health care services • HIV/AIDS program tends to rely on donor agencies

5. Timika • A mining town in Papua province where a large gold mining company is operating with 12,000 male employees • Approximately 600 FSWs • In 1997, a survey among 462 mining employees • Visited brothel complex (14%) and local bars (20%) • Low level of condom use (3%) • Not aware of their risk of contracting STI/HIV infection (48%)

6. 1995 - First HIV cases • 1997 – A partnership between District Health Office and PTFI in developing HIV Prevention program was established: • Behavior change • Provision of STI care

7. Aim of study • Prevalence and risk factors associated with STIs among the FSWs attending the STI clinic for the first time from January 1997 – June 2002 Methods • We recruited FSWs from the only brothel, local bars and from the street

8. Methods • Every month each bar/brothel receives a reminder of the availability of clinic appointments • Clinic participation is voluntary • A clinic administrator • acts as an ombudsman solving problems • organizing clinic visits • maintaining a log of the number of FSWs living in each bar or house at the brothel

9. Variables • Sociodemographics • Type of sex worker (Brothel, Bar, Independence / freelance / street) • Age and place of origin • Sexual behavior • Contraceptive use • Having regular partner and their occupation • Frequency of sex in the past one week • Condom use • Consistent (100% condom use during their sexual acts in the past one week) • Inconsistent (less than 100% or no condom)

10. Specimens & tests • Posterior fornix vaginalis tested for Trichomonas vaginalis (TV) by wet mount • Endocervical samples tested for Nesseria gonorrhoeae (NG) by culture and LCR • Urine samples tested for Chlamydia trachomatis (CT) by LCR • Blood samples tested for • RPR and TPHA • HIV tests (Immunoblot, ELISA) confirmed by WB

11. Statistical Methods • Data of FSWs who attended the STI clinic for the first time were selected, almost all of whom are newly arrived in Timika • Data were analysed by EPIINFO 6.4 and SPSS version 11.5 • To test for trends over time of categorical variables, a logistic regression model was used. • To adjust for multiple risk factors, multivariate analysis was performed: variables associated with STIs on univariate analysis were included in a backward selection logistic regression model

12. Results • Socio-demographic characteristics • Most of the 3086 FSWs recruited worked in the brothel (63%) or bars (34%) and most originated from Java (70%) or Sulawesi (25%) • Age mean (median) =25 (26)

13. Table 1. Sexual behaviour characteristics of female sex workers attending STI Clinic in Timika, 1997 to 2002 by type of sex worker

14. Table 2. Trend socio-demographic characteristics of female sex workers attending STI Clinic in Timika by year

15. Fig. 1. Annual prevalence rates of CT, NG, TV, syphilis, and HIV among female sex workers attending STI Clinic in Timika 1997-2002. P=0.005 P=0676 P=0.003 P=0.546 P=0.003

18. Discussion • First study of its kind in Indonesia • Suggests a partnership with business corporation in developing HIV/AIDS intervention program is feasible • Young age, high frequency of sex, having regular partner and place of origin can be predictors in choosing an intervention for behavioural change

19. Discussion • This study revealed an increase in consistent condom use over time. However, the rate is still very low, which may have little impact on reducing the transmission of STIs. • Increase in the prevalence of HIV infection is worrying, as the prevalence of other STIs such as CT, NG and syphilis in this group study remains high

20. Discussion (Limitations) • There was low representation of women from the street / freelance / independence (3,9%) • There were incidents of closing brothel/bars in year 1998 and 1999 which may dramatically reduce the number of sexual encounters • The frequency of screening was reduced from every month to every two months in 2001, and so newly-arrived FSWs who came to the clinic in 2001 and thereafter were exposed to more partners • Accuracy for NG testing - In 1997 and 1998, the NG culture was performed with manual CO2 incubator

21. Conclusions • High prevalence of STIs, low consistent condom use and increasing HIV prevalence among these FSWs require enhanced interventions • FSWs in Indonesia are vulnerable to HIV transmission, and a partnership with industry can help in developing an intervention program • Further study on freelance or street FSWs is required

22. Thank you