HASIL PENELITIAN
Second Report on AIDS Related
Attitudes and Sexual Practices among
Jakarta's Male Transvestites, 1995
Imran Lubis*, John Master*, A. Munif*, Nancy lskandar*, Myrna Bambang*,
Alex Papilaya*, Runizar Roesmin**, S. Manurung***, A. Graham****
* AIDS and STD Prevention Program, Indonesian Public Health Association
** WHO Consultant on AIDS, indonesia
* * * Social Dept. Jakarta Municipality
**** Virology Program, NAMRU-2 Jakarta, Indonesia
INTRODUCTION
Although the AIDS virus has been identified, neither a
method for preventing infection nor an effective method of
treatment has yet been developed, and the disease is fatal. Only
health education campaign to change high-risk sexual behavior
to a lower one can prevent the spread of HI V/AIDS.
The first AIDS case reported in Indonesia was a tourist
found in Bali in April 5, 1987. Until 31 July 1995 the number of
HIV/AIDS cases reported to the Department of Health has
increased to 316 where 77 among them were AIDS. HIV/AIDS
has been reported from 15 out of 27 provinces in the islands of:
Java, Sumatera, Kalimantan, Irian Jaya, Bali, West Nusateng-
gara and Maluku. The mode of transmission were as follows:
24.0% homosexual/bisexual, 58.9% heterosexual, 1.3% IVDU,
0.6% blood transfusion, 0.6% factor VIl/hemophiliac, 14.6%
unknown. The most affected age group for AIDS were 30-39
years old and for HIV were 20-29 years old,
In Jakarta, the number of male transvestites is estimated to
be close to 5,000. They are referred to as Waria, a combination
of the Indonesian words Wanita, meaning women, and pria,
meaning man. Physically they are men but psychologically they
are women, and their sexual activities is similar to male homo-
sexual. Most of the Waria have day-time jobs but at night they
become self-employed commercial sex workers (CSW). Contact
with clients is usually established in places of entertainment, in
parks or on the street; their careers as CSW are believed to span
several years longer than those of their female counterparts.
Since 1991, the Indonesian Public Health Association (IPHA),
Namru-2 and WHO has been conducting HIV/AIDS campaign,
condom distribution, STD treatment and monitoring of the Ja-
karta Waria for sexually transmitted disease including HIV. This
is the second report on the attitude and sexual pra of Waria in
Jakarta. From the first 830 specimen collected in 1991-1993
we found one HIV positive Waria from South Jakarta by Elisa
and confirmed by Western Blot test. This report covered a period
from May - July 1995 where among 253 Waria we found
additional two HIV positives (one weak positive) from North
Jakarta.
MATERIAL AND METHOD
Four Warias recognized as popular opinion leaders by their
peers, who have been working with this program since 1991,
were recruited as field HIV/AIDS educators. Before the program
started, they were trained again with the knowledge and skill to
conduct HIV/AIDS education campaign, condom usage demon
stration, capability to advocate the change of sexual practices
from high to low risk, to conduct interview to fill up questioinnaire
on a study. One physician was appointed to explain the clinical
signs and treatment of HIV/AIDS, to conduct physical diagnosis
and treatment on any Waria who is suffering from any suspected
STD. With informed consent, one medical technician was
responsible in blood drawing, separation and storage. Namru-2
conduct ELISA test and Western Blot test for confirmation of
HIV infection.
Printed information thatgraphically depicted high-risk sexual
behavior and the proper use of condoms were supplied. Pictures
on clinical signs of AIDS cases such as buccal lesion, various skin
lesion, etc. were shown to participants. They were coached the
proper way to ask questions dealing with the sensitive issues of
sexual attitudes and behavior and the legal requirement of obtain-
ing informed consent. The importance of blood testing for HIV
antibodies, including pre-test and post-test counseling, was
explained and procedures were described.
Approximately 500 Waria were invited to lunch gathering,
at a beauty salon, South Jakarta Municipal Hall, training center
etc, or at the house of one of the leaders. Members of the IPHA
Cermin Dunia Kedokteran No. 117, 1997
22
team attended also. The leaders used visual aids to make short
presentation on the epidemiology, sociology, economic and
clinical aspect of HIVIAIDS. They explained the importance of
AIDS education and stressed why they thought that the Waria,
including themselves and their friends, were at significant risk
for becoming infected with HIV. Emphasis was focused upon
reasons and methods for altering sexual behavior. Demonstration
for the proper use of condoms with water based lubricants were
presented and after obtaining informed consent, interviews on
sexual behavior patterns and attitudes towards AIDS were con-
ducted in private, on a one to one basis. Any Waria who suffered
of any STh were treated with antibiotics. Finally, blood was
collected voluntarily for HIV antibody testing and condoms were
distributed, 100 condoms each.
RESULTS
A total of 253 out of 500 Waria agreed to participate this
study, conducted from May-July 1995, mostly from East Jakarta
(48.3%); and from South Jakarta (19.3%), Central Jakarta (13.9%),
West Jakarta (12.2%), North Jakarta (6.3%). Their mean age is
31.1 years old with a minimum of 12 years old and maximum 65
years old; 76.8% of them are commercial sex workers. They has
been living in Jakarta for an average of 11.9 years.
During the last three weeks they have sex with men at an
average of 5 persons, with bisexual man 0.2 persons. 65.6%
received payment for sexual contact, 15.2% never being paid,
and 19.2% sometimes received money.
From the last 5 sexual contacts they use condom in only 1.2
times, and their sexual behavior are: conducting anal sex only
2.7 times, oral sex 3.5 times and masturbation 1.4 times. Among
them, 36.6% have had sexual contact with foreigners.
The reasons for not using condom are: forget to use 35.3%,
does not like to use 21.0%, their partner does not like to use
condom 38.2% and does not know about condom 5.5%.
32.9% knows that there is a risk to get HIV/AIDS infection
for themselves, 19.0% assumes no HIV infection risk and 48.1%
does not know. Whereas 27.6% know that there is risk HIV/AIDS
infection for their partner, no risk 18.2% and does not know
54.2%.
DISCUSSION
Education campaign on methods of HIV/AIDS prevention
and intervention remain the most effective means in informing
population on how their sexual behavior influences their risk for
HIV infection. In the industrialized nations such campaigns are
carried out effectively through the media: television, radio,
newspaper and magazines. In developing countries, however,
the majority of people who need the HIV/AIDS information do
not have access to those methods. Thus, educational campaigns
must be conducted on the streets or in the local neighborhoods,
bath houses, massage parlors and entertainments.
In the previous research (1993) we found one out of 830
Waria from South Jakarta positive of HIV infection based on
Elisa and Western Blot test. In this study, (May to July 1995) we
collected 253 blood specimen, and two samples from North
Jakarta are positive for HIV antibody, one is weakly positive in
Western Blot test suggesting an early HIV infection. An increase
of confirmed HIV cases in Waria in Jakarta from 1993 to 1995
means that the epidemiological situation of HIV/AIDS in Waria
in Jakarta has already becoming more dangerous and prevention
activities should become a priority.
Perception on how to get HIV infection were not signifi-
cantly changed (Table 1). There is a difference in the average age
group; 39.0 year old and in 1993 is 31.1 years old in 1995.
Younger Waria have higher proportion of ignorance; they
perceived no risk for themselves (19.9% vs 6.4%) and for their
friends (18.2% vs 5.8%).
Table 1. Perceived Risk of IIIV Infection of Jakarta Waria in 1993 and
in
1995
For themselves
For their friends
Perceived risk of
HIV infection
1993
n = 330
1995
n = 253
1993
n = 227
1995
n = 253
Yes
No
Not known
29.1%
6.4%
64.5%
29.1%
19.9%
50.8%
23.8%
5.8%
27.6%
18.2%
54.2%
70.4%
The turn-over rate of Waria is not known; however, in 1995
there were a lot of younger Waria participating in the HIV/AIDS
Campaign. This might suggest that a younger group of Waria
has been replacing older one.
Multiple sex partner is one of the high risk behavior that
promote HIV/AIDS transmission among Waria. In 1993, 83.2%
of Waria has 2-4 male partner during the last 3 weeks period,
whereas in 1995, 76.8% of Waria have an average of 5.1 male
partner. Waria who had sex relationship with foreigner in 1993
were 53.6%, in 1995 decreasing to 36.6%; in 1987 there were
63.1% (Judonarso et al).
Most of 1995 Waria series received payment for sex (65.6%),
and only 1.2 times out of the last 5 times sex contacts used
condoms. This failure were mostly because of forgetfulness
(35.3%) or partner does not like condom (38.2%).
As found in the previous study that the syphilis sero pre-
valence (STS) in Waria were 39%. Health seeking behavior for
STD treatment is shown in Table 2.
Table 2. The Frequency of Receiving STD Treatment Among Waria in
Jakarta,
1995
STD Treatment
Percentage
Never
Once
Sometimes
Often
84.2
6.5
9.3
2.4
During HIV/AIDS Campaign, it was advocated that when
they have any kind of sexually transmitted disease, Waria is not
allowed to have sex evçn iising condom. To increase STD
treatment coverage, we have to strengthen the network of STD
Clinics, the capability and quality of diagnosis and treatment of
STD, and the distribution of information on the existing STD
clinics. In Indonesia there is still debate on whether we use
syndromic approach or etiological approach of STD treatment;
Cermin Dunia Kedokteran No. 117, 1997 23
the latter is more difficult to be applied in a community setting.
Condoms can be a highly effective method on HIV/AIDS
prevention if they are used correctly and regularly. When properly
used, condoms also provide protection against a broad range of
sexually transmitted diseases. These include not only traditional
venereal diseases, such as gonorrhea and syphilis, but also other
infections such as herpes and chlamydia.
More information, better availability and better promotion
of condoms can increase condom use. Thus attention has turned
to various ways of distributing condoms, including : commercial
sales, distribution though family planning clinic, community-
based distribution by peer leaders, social marketing. In this
study, Waria access to condom is from their sexual partner
21.1%, from warung (small shop) 7.8%, from drugstore 12.4%
and from health facilities 58.7%.
Unfortunately, there is inconsistent use and unwillingness
to use condoms, so the method may not be as acceptable. Among
the most important reasons that people cite for not using condoms
are: decreased male sensitivity and the poor image of condoms
due to their traditional association with venereal disease and
prostitution.
Failure of condoms to protect transmission is usually caused
by condom break caused by different sexual behavior and sexual
practices, lubricant that damage the condom and whether con-
doms were weakened by poor conditions in storage or shipment
and whether the condom was made with weak spot, hole or other
defect.
Experiences of Waria who use condom were in Table 3.
Table 3. Condom Use Experiences in Waria in Jakarta (1995)
Condom use experiences
Yes
No
1. Never
2. Broke
3. Size not fit
4. Reuse
5. With lubricant
6. Without lubricant
7. With cream
26.0%
15.6%
13.0%
25.2%
21.2%
15.2%
20.9%
71.4%
75.3%
76.2%
64.8%
67.5%
76.2%
70.1%
More than 50% of the Waria who participated in this com-
munity-based campaign already knew that HIV was transmitted
sexually, (Table 4) but yet they continued to practiced high risk
sexual behavior, receptive anal sex without condoms with
multiple partners each week. Although they were aware that such
behavior frequently resulted in the sexual transmission of
diseases, the majority did not understand that their activities were
also placing them at a high risk for acquiring an HIV infection.
Table 4. Knowledge on HIV Mode of Transmission in Waria in Jakarta,
1995
HIV transmitted through
Yes
No
Don't know
1. Kissing
2. Toilet
3. Anal Sex
4. Oral Sex
5. Masturbation
6. Shake hand
7. Blood transfusion
8. Hair cut
9. Utensil
44.1%
15.5%
83.1%
67.5%
13.1%
13.5%
67.2%
39.6%
20.3%
24.8%
47.6%
4.6%
7.2%
48.0%
49.6%
10.6%
31.3%
46.0%
31.1%
36.9%
12.3%
25.3%
38.9%
36.9%
22.2%
29.1%
33.7%
Stigmatization, discrimination could be induced by incorrect
knowledge of HIV transmission mode such as kissing (44.1%),
toilet (15.5%), shake hand (13.5%), hair cut (39.6%) and using
utensil (20.3%).
Unlike the previous report in 1991-1993 in which no HIV
cases was found, three Waria in Jakarta have been confirmed of
having HIV infection in 1994-1995. This number might be still
under reported since the surveillance number of this study is still
small. However this has already shown an increase of HIV cases.
Condoms promotion in Waria community should be launched
immediately in order to prevent further spread. Policy makers,
health administrators are encouraged to help IPHA to see the
potential effectiveness and feasibility of condom program and
to set condom program as a high priority in HIV/AIDS control
programs in Waria in Jakarta.
ACKNOWLEDGEMENT
This study was supported by WHO SEARO through Directorate CDC &
EH, Ministry of Health, The Republic of Indonesia
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A lie which is half a truth is the blackest of lies (Tennyson)
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