A COLLABORATION BETWEEN THE MINISTRY OF HEALTH AND THE NATIONAL AIDS COMMISSION INDONESIA 2014

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TECHNICAL REPORT:

  

2013 SERO-SENTINEL SURVEILLANCE

AND

2013 RAPID BEHAVIORAL SURVEY

  A COLLABORATION BETWEEN THE MINISTRY OF HEALTH AND THE NATIONAL AIDS COMMISSION

TECHNICAL REPORT: 2013 SERO-SENTINEL SURVEILLANCE AND 2013 RAPID BEHAVIORAL SURVEY

  vey veillance And 2013 Rapid Behavioral Sur A COLLABORATION BETWEEN THE MINISTRY OF HEALTH AND THE NATIONAL AIDS COMMISSION Technical Report: 2013 Sero-Sentinel Sur vey Ind 616.91

Indonesia. Kementerian Kesehatan RI.

Katalog Dalam Terbitan. Kementerian Kesehatan RI veillance And 2013 Rapid Behavioral Sur Direktorat Jenderal Pengendalian Penyakit dan Kementerian Kesehatan RI. 2014 And 2013 rapid behavioral survey. - Jakarta: Technical report: 2013 sero - surveilance survey Penyehatan Lingkungan III. HEALTH SURVEYS II. ACQUIRED IMMUNO DEFICIENCY VIRUS 1. Judul

ISBN 978-602-235-796-4

I. HUMAN IMMUNODEFICIENCY SYNDROME

  IV. BEHAVIORAL RISK FACTOR Technical Report: 2013 Sero-Sentinel Sur SURVEILLANCE SYSTEM V. BEHAVIORAL RESEARCH Summary

  This report contains the results of the 2013 HIV Sero-Surveillance Survey and the Rapid Behavioral surveys. In its first part, the report describes the results of the 2013 HIV Sero-Surveillance Survey Survey (SSS) conducted by the Ministry of Health (MOH) and in its second part, it provides the results of the 2013 Rapid Behavioral survey (RBS) conducted by the National AIDS Commission (NAC).

  The 2013 Sero-Surveillance Survey was conducted among direct female sex workers (DFSW), people who inject drugs (PWID), men who have sex with men (MSM) and transgenders in 22 cities while the 2013 Rapid Behavioral Survey included MSM, DFSW, and PWID in 8 cities.

  The Sero-Surveillance Survey aimed to determine the magnitude of the HIV epidemic and syphilis among key populations and the Rapid Behavioral Survey studied the prevalence of associated risk factors. The results of these surveys will serve to set targets for the new national HIV/AIDS national strategic plan and for planning and/or modifying existing programs to prevent HIV in Indonesia. DFSW and transgender participants were sampled using a two stages probability proportional to size method while MSM and PWID were sampled using the respondent driven sampling method (RDS). The target sample sizes were 250 for each key population per site for the 2013 SSS and 240 per site for the 2013 Rapid Behavioral Survey.

  A total of 6603 participants were recruited for the 2013 SSS. Of those, 3685 were DFSW, 985 were transgenders, 978 were PWID, and 985 were MSM. The total number of participants in the 2013 Rapid Behavioral Survey was 2829. Of vey these, 1120 were DFSW, 989 were PWID, and 720 were MSM.

  Characteristics of Respondents

  In the 2013 SSS, direct female sex workers represented 55.8% of participants, PWID and transgenders represented each 14.8%, and MSM represented 14.5% of participants. The distribution of all key populations by location was as followed: 14% were from veillance And 2013 Rapid Behavioral Sur Malang, 15% from Surabaya, 15% from Jakarta and 15% from Bandung. All the other locations had less than 7% of the participants. In the 2013 Rapid Behavioral Survey, 25% of the participants were MSM, 40% DFSW and 35% were PWID. By location, Jakarta, Bandung and Surabaya contributed each 17% of participants; Denpasar 14% and Malang, Medan and Banyuwangi contributed each 8%. Technical Report: 2013 Sero-Sentinel Sur Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey HIV and STI Prevalence ƒ

  HIV prevalence was highest among the PWIDs with 44.5% and it was followed by transgenders with 19%, MSM with 17.3% and DFSW with 10%.

  Malang and Surabaya did not register any case of syphilis among PWID in the 2013 Sero-Surveillance Survey

  ƒ

  HIV prevalence among the MSM increased significantly from 10.6% to 17.3% [p< 0.000002, OR=0.56 (0.43-0.73)]

  ƒ

  This comparison included only data from cities which participated to the two surveys. The results showed that:

  The comparison of HIV and syphilis prevalence between 2013 Sero-Sentinel Survey and 2011 Integrated Biological and Behavioral Survey

  ƒ The lowest prevalence of syphilis among DFSW was recorded in Batang (1.2%).

  The prevalence of syphilis among DFSW was highest in Jayawijaya (33.3%), followed by Ambon (10.2%), Denpasar (7.3%) and Malang and Lampung (6.8% and 6.4% in respectively).

  ƒ

  Among transgenders, Jakarta had the highest syphilis prevalence with 29.2%, followed by Surabaya with 17.1%, Bandung with 14% and Malang was last with 4,2%

  ƒ

  The highest prevalence of syphilis among MSM was recorded in Bandung at 15.4%, followed by Surabaya and Jakarta with 14.6% and 14.2% respectively. In Malang, syphilis prevalence among MSM was 6.7%.

  ƒ

  ƒ

  ƒ

  The highest prevalence of syphilis prevalence among PWID, was recorded in Medan (7.3%), followed by Jakarta (3.8%) and Bandung (1.3%).

  ƒ

  The highest prevalence of syphilis was among transgenders (16.2%), followed by MSM (12.7%) and direct female sex workers (5.5%).

  ƒ The prevalence of syphilis was 6.6% among all the participants in the 2013 SSS. ƒ

  HIV prevalence among DFSW was 20.3% in Denpasar and Jayapura, Ambon, and Surabaya had HIV prevalence among DFSW above 10%

  ƒ

  The highest prevalence among DFSW was found in Jayawijaya (32.5%) and the lowest was noted in Deli Serdang (1.6%)

  ƒ

  Jakarta had the highest HIV prevalence among transgenders with 29.6% followed by Surabaya with 27.5%, Bandung and Malang with 9.6% and 9.2% respectively

  ƒ

  HIV prevalence among MSM was highest in Surabaya with 22.1% followed by Bandung (21.3%), Jakarta (19.6%) and lastly by Malang (6.3% )

  ƒ

  The highest HIV prevalence among PWID was found in Malang (59.1%) and the lowest in Bandung (27.1%). In Jakarta, Surabaya and Medan HIV prevalence among PWID was 49.2%, 48.8% and 27.3% respectively

  HIV prevalence among transgenders decrease significantly from 23.8% to 19%

  ƒ

  The prevalence of syphilis significantly declined from 27.5% to 16.2% among transgenders. [p<0.000001, OR=1.96 (1.57-2.44)] and from 8.8% to 5% among DFSW [p<0.000001, OR=1.82(1.48-2.24)]

  ƒ

  HIV prevalence increased significantly in Malang from 36.4% to 59.1% [p<0.001, OR=0.4 (0.27-0.58)]

  ƒ

  HIV prevalence among MSM increased in Bandung and in Surabaya from 10.4% to 21.3% [p=0.001, OR=0.43(0.26-0.72)] and from 10% to 17.3% [p<0.001, OR=0.53(0.4-0.69)]

  ƒ

  HIV prevalence among transgenders significantly decline in Malang from 16.8% to 9.2% [p=0.017, OR=2.01(1.16-3.48)]

  ƒ

  The prevalence of syphilis among transgenders declined significantly in Bandung from 26.4% to 14% [p<0.001, OR=2.19(1.39-3.46)] and in Malang from 20.8% to 4.2% [p<0.001, OR=6.07(3-12.26)]

  ƒ

  HIV prevalence among DFSW significantly decreased in Jakarta and in Bandung from 10.5% to 3.8% [p=0.0046, OR=3 (1.38-6.56)] and from 20.7% to 9.4% [p=0.0013, OR=2.53(1.45-4.4) respectively

  ƒ

  The overall syphilis prevalence among DFSW declined from 9.8% from the 2011 Integrated Biological and Behavioral Survey to 5.7% in the 2013 Sero-Surveillance Survey.

  ƒ

  Syphilis prevalence among DFSW significantly decreased in five of the 15 locations surveyed. It decreased from 16.6% to 4.8% [p<0.05, OR 0.42(0.28-0.63)] in Deli Serdang. It also decreased from 11.6% to 3.3% [p=0.001, OR=3.3(1.5-6.75)] in Batam, from 10.4% to 2.8% [p<0.001, OR=4.03(1.7-9.72)] in Bandung; from 12.4% to 4.6% [p=0.003, OR=2.96(1.45-6.04)] in Surabaya and from 13.4% to 1.2% [p<0.0001, OR=13.1(3.88-44.2)] in Batang. Trends of HIV prevalence among Key Populations, 2007, 2011-2013 vey

  Risk behaviors among key population from the 2013 Rapid Behavioral Survey ƒ

  The highest number of clients per DFSW per week was noted in Denpasar (14 clients) followed by Malang (eight clients) and Banyuwangi (seven clients).

  ƒ

  Condom use during the last commercial sexual intercourse among DFSW was 76.5% in Denpasar, 71.3% in Malang and Banyuwangi and 68.8% in Semarang. veillance And 2013 Rapid Behavioral Sur

  ƒ

  Consistent condom use during the last week preceding the survey was 65.5% in Denpasar, 38.3% in Semarang, 35.1% in Banyuwangi and 24.2% in Malang.

  ƒ

  More than two thirds (73%) of MSM in Jakarta used condoms during their last sexual intercourse, compared to 43% in Bandung and 53% in Surabaya.

  ƒ In none of the three cities surveyed, MSM reported the use of injectable drugs. ƒ

  The proportion of PWID who have tested for HIV was highest in Medan (66.2%); followed by Jakarta (64%), Surabaya (47.5%), Bandung (41%), and Semarang (25%). Technical Report: 2013 Sero-Sentinel Sur

  ƒ

  Jakarta, Bandung, and Semarang had rates of PWIDs who shared needles at their last injection above 10%

  ƒ

  The proportion of PWIDs sharing needles was lowest in Surabaya (0.8%) followed by Medan (3.1%).

  Comparison between risk behaviors between 2013 Rapid Behavioral Survey and 2011 Integrated Biological and Behavioral Surveyin the some locations ƒ

  The median number of clients per DFSW per week remained high

  ƒ

  Significant declined of the proportion of DFSW who used condom during their last sexual encounter in Malang from 83.2 % to 71.3 % [P=0.0025, OR= 1.99 (1.29-3.07)] and was from 90 % to 76.5% [P=0.00003, OR=2.74(1.71-4.4) in Denpasar.

  ƒ

  Significant decline of proportion of reported consistent condom use during the last week prior to the survey among DFSW from 35.1% to 12.5% [P<0.001, OR=3.78(2.38- 5.99)] in Bandung and from 44.9% to 24.2% [P<0.001, OR=2.57 (1.74-3.780] in Malang.

  ƒ

  Significant increase in condom use during commercial sex among DFSW during the same period from 49.6% to 65.5% in Denpasar [P<001, OR=0.52 (0.38-0.72)].

  ƒ

  The percentage of MSM injecting drugs dropped from 5% to 0% in Jakarta between 2011 and 2013 (p<001) but remained stable in the other cities.

  ƒ

  The proportion of MSM who used condom during their last sexual encounter dropped significantly in Surabaya from 75.9% to 53% [P=00001, OR=2.79(1.9-4.1)].

  ƒ

  The comparison of data from the 2011 Integrated Biological and Behavioral Survey and the 2013 Rapid Behavioral Survey revealed that there have been a significant drop vey in the proportion of PWIDs who ever tested for HIV from 59.6% to 41.3% in Bandung [P<0.001, OR=2.1(1.5-3)]. This was also noted in Denpasar from 77.6% to 47.5% [P<0.001, OR=3.83(2.59-5.66)] from 2011 Integrated Biological and Behavioral Survey to the 2013 Rapid Behavioral Survey

  ƒ

  During the same period of time, proportion of PWIDs who shared needles during the last injection dropped significantly from 18 % to 10.8 % [P=0.033, OR=1.81(1.07-3.04)] veillance And 2013 Rapid Behavioral Sur in Bandung and from 8.4 % to 0.8 % [P=0.0002, OR=10.9(2.5-47.07)] in Surabaya.

  The trends analysis from 2007 to 2013 showed that: ƒ

  Statistically significant decline of HIV prevalence of about 15% among PWIDs in the locations surveyed from 52.3% to 44.5% between 2007 and 2013. [p=0.00036, OR=0.729].

  ƒ

  HIV prevalence among MSM increased steadily between 2007 and 2013 from 5% to 17.3%. This represented an increase of more than 200% from 2007.

Technical Report: 2013 Sero-Sentinel Sur Syphilis prevalence increased significantly among MSM from 1% to 12.7% [p=00001,

ƒ

  ƒ

  HIV prevalence increased among MSM in Jakarta, Bandung and Surabaya from 8.1% to 19.6% [p=0.00031, OR=2.837], from 2% to 21.3% [p<0.00001, OR=13.22] and from 5.6% to 22.1% [p<0.00001, OR=4.778] respectively.

  ƒ

  The prevalence of syphilis increased among MSM in Jakarta from 3.2% to 14.2% [p=0.00013, OR=5.055]; in Bandung from 5.6% to 15.4% [p=0.034, OR=2.129] and in Surabaya it increased from 4% to 14.6% [p=0.00008, OR=4.098].

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  The analysis revealed that HIV prevalence among transgenders decreased by 5% from its 24.4% level in 2007 to 19% in 2013. [p=0.00284, OR=0.726].

  ƒ

  The prevalence of syphilis declined among transgenders from 24.4% to 16.2% [p=0.00001, OR=0.599] and among DSFW from 6.2% to 5% [p=0.0317, OR=0.796].

  ƒ

  HIV prevalence among transgenders significantly declined in Malang 16.8% to 9.2% [p=0.00792, OR=0.497] from 2007 to 2013.

  ƒ

  The prevalence of syphilis among transgenders significantly declined from 25.2% to 14% in Bandung [p=0.00204, OR=.0483]; from 28.8% to 17.1% in Surabaya [p=0.00198, OR=.509] and from 20.8% to 4.2% [p<0.00001, OR=0.165]in Malang between 2007 and 2013

  ƒ

  HIV prevalence significantly declined among PWIDs by 50% in Medan and in by 37% in Bandung between 2007 and 2013 [p=0.00014, OR=0.496].

  ƒ

  The prevalence of syphilis increases significantly among PWIDs in Jakarta and Bandung from 0.1% to 3.8% [p=0.03, OR=9.86] and from 0% to 1.3% [p=0.033, OR=9.818]

  ƒ

  Between 2007 and 2013, HIV prevalence declined significantly among DFSW from 6.1% to 1.6% [p=0.00662, OR 0.254] in Deli Serdang; from 10.2% to 3.8% [p=0.00654, OR=0.337] in Jakarta and from 6.6% to 2.5% [p=0.0229, OR=0.36. in Semarang.

  ƒ

  HIV prevalence among DFSW increased in Surabaya from 6.5% to 12.5% [p=0.02754, vey OR=2.089] and in Denpasar from 14.1% to 20.3% [p=0.04, OR=1.56] between 2007 and 2013

  ƒ

  Syphilis prevalence declined among DFSW in Deli Serdang from 12.9% to 4.8% [p=0.0037, OR=0.342], in Batam from 16.8% to 3.8% [p<0.00001, OR=0.198] and in Jakarta from 9.2% to 2.5% [p=0.00084, OR=0.253] between 2007 and 2013

  ƒ

  The prevalence of syphilis among DFSW also declined in Jayapura from 6% to 2.4% [p=0.027, OR=2.6(1.08-6.23)].

  ƒ veillance And 2013 Rapid Behavioral Sur

  The prevalence of syphilis among DFSW increased in Batang from 0.9% to 1.2% [p=0.00713, OR=1.488] and in Ambon from 5.2% to 10.2% [p=0.048, OR=0.47(0.22-1)]

  ƒ

  The data showed a strong relation between HIV and syphilis prevalence among all the key populations (R-Squared=0.9656).

  Technical Report: 2013 Sero-Sentinel Sur

CHAPTER I: INTRODUCTION 13

  3.1.3. HIV prevalence

  19

  2.4. Analysis

  19 CHAPTER III:RESULTS 21

  3.1. Results of the 2013 HIV Sero-Surveillance Survey

  21

  3.1.1. Participation rate

  21

  3.1.2. Characteristics of the Population Groups

  22

  22

  19

  3.1.3.1. HIV prevalence among different key population

  22

  3.1.3.2. HIV prevalence among PWID

  23

  3.1.3.3. HIV Prevalence among MSM

  23

  3.1.3.4. HIV prevalence among transgenders

  24

  3.1.3.5. HIV prevalence among DFSW

  25 Table of Contents

  2.3. Implementation

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey SUMMARY 1 TABLE OF CONTENTS

  7 LIST OF TABLES

  16

  10 LIST OF FIGURES

  11 LIST OF ABBREVIATIONS 12

  1. Background

  13

  2. Scope

  15

  3. Outcomes

  15 CHAPTER II: METHODOLOGY 16

  2.1. Sero-Surveillance Survey

  2.1.1. Selection criteria

  19

  16

  2.1.1.1. Sampling

  16

  2.1.2. Biological testing and quality assurance

  17

  2.1.3. Locations

  18

  2.2. Rapid Behavioral Survey

  19

  2.2.1. Sample size

  2.2.2. Tools

  3.1.4. Prevalence of syphilis

  27

  3.1.4.1. Syphilis prevalence among different key population

  27

  3.1.4.2. Prevalence of Syphilis among PWID

  27

  3.1.4.3. Prevalence of syphilis among MSM

  27

  3.1.4.4. Prevalence of syphilis among transgenders

  28

  3.1.4.5. Prevalence of syphilis among DFSW

  29

  3.1.5. Comparison between HIV and syphilis prevalence between 2011 Integrated Biological and Behavioral Survey and 2013 Sero-Surveillance Survey

  31

  3.1.6. Trends analysis of HIV and syphilis prevalence among key populations between 2007 and 2013

  33

  3.1.6.1. Trends of HIV prevalence among Key Populations, 2007-2013

  33

  3.1.6.2. Trends of HIV Prevalence among Key Populations by Location, 2007-2013 34

  3.1.6.3. Trends of HIV Prevalence among PWIDs by Locations, 2007-2013

  34

  3.1.6.4. Trends of Syphilis Prevalence among PWIDs by Locations, 2007-2013

  35

  3.1.6.5. Trends of HIV Prevalence among MSM by Locations, 2007-2013

  35

  3.1.6.6. Trends of Syphilis Prevalence among MSM by Locations, 2007-2013

  36

  3.1.6.7. Trends of HIV Prevalence among Transgenders by Locations, 2007-2013 36

  3.1.6.8. Trends of Syphilis Prevalence among Transgenders by Locations, 2007-2013 37

  3.1.6.9. Trends of HIV Prevalence among DFSW by Locations, 2007-2013

  37

  3.1.6.10. Trends of Syphilis Prevalence among DFSW by Locations, 2007-2013

  38

  3.1.6.11. Relationship between HIV Prevalence and Syphilis prevalence among Different Key Populations, Sero-Surveillance Survey 2013

  39

3.2. Results of the 2013 HIV Rapid Behavioral survey

  40 vey

  3.2.1. Participation rate

  40

  3.2.2. Risk behaviors among key population

  40

  3.2.2.1. Direct female sex workers

  40

  3.2.2.2. Men who have sex with men

  41

  3.2.2.3. People who inject drugs

  42

  3.2.3. Comparison between risk behaviors between the 2011 Integrated Biological and Behavioral Survey and 2013 Rapid Behavioral Survey 45 veillance And 2013 Rapid Behavioral Sur

CHAPTER IV: CONCLUSION, DISCUSSION AND RECOMMENDATIONS

  46

  4.1. Conclusion

  46

  4.2. Discussion

  48

  4.3. Recommendations

  50 Technical Report: 2013 Sero-Sentinel Sur REFERENCE

  51 Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey

  Table 1 : List of provinces, districts/cities and the number of the participating sites

  31 Table 13 : Prevalence of Syphilis among PWID by Location, 2011-2013

  43 Table 21 : Prevalence of risk Behavior among PWID in Semarang, 2010-2013

  43 Table 20 : Prevalence of risk Behavior among PWID in Bandung, 2010-2013

  43 Table 19 : Prevalence of Risk Behavior among PWID in Jakarta, 2010-2013

  Table 18 : Prevalence of risk Behavior among PWID in Medan, 2010-2013

  41 Table 17 : Prevalence of Risk Behaviors among MSM inJakarta, Bandung and Surabaya, 2011-2013 42

  41 Table 16 : Prevalence of Risk Behaviors among DFSW in Malang and Denpasar, 2011-2013

  40 Table 15 : Prevalence of Risk Behaviors among DFSW in Semarang and Banyuwangi, 2011-2013

  32 Table 14 : Sample sizes by locations for the Rapid Behavioral Survey, 2013 Sero-Surveillance Survey

  30 Table 12 : Comparing HIV prevalence among key population in the same locations for IBBS 2011 and Sero-Surveillance Survey 2013

  18 Table 2 : Planned Sample Size and Sampling Method by Target Population and Location 21 Table 3 : Prevalence of HIV and Syphilis per Target Group of Key Affected Populations in the Sero-Surveillance Survey 2013

  29 Table 11 : Prevalence of Syphilis among the DFSW by Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013

  28 Table 10 : Prevalence of Syphilis among the Transgenders by Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013

  27 Table 9 : Prevalence of Syphilis among the MSM per Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013

  26 Table 8 : Prevalence of Syphilis among PWID per Location in IBBS 2011 and Sero- Surveillance Survey 2013

  25 Table 7 : HIV Prevalence of DFSW per location in IBBS 2011 and Sero-Surveillance Survey 2013

  24 Table 6 : HIV Prevalence among the transgenders per location in IBBS 2011 and in Sero- Surveillance Survey (SS) 2013

  23 Table 5 : HIV Prevalence among the MSM per Location in IBBS 2011 and in Sero- Surveillance Survey (SS) 2013

  22 Table 4 : HIV Prevalence among PWID per Location in IBBS 2011 and Sero-Surveillance Survey 2013

  44 List of Tables

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey

  Figure 1 : Trends of HIV Prevalence among Key Populations, 2007-2013

  33 Figure 2 : Trends of HIV Prevalence among Key Population by Location, 2007-2013

  34 Figure 3 : Trends of HIV Prevalence among PWIDs by Locations, 2007-2013

  34 Figure 4 : Trends of Syphilis Prevalence among PWIDs by Locations, 2007-2013

  35 Figure 5 : Trends of HIV Prevalence among MSM by Locations, 2007-2013

  35 Figure 6 : Trends of Syphilis Prevalence among MSM by Locations, 2007-2013

  36 Figure 7 : Trends of HIV Prevalence among Transgenders by Locations, 2007-2013

  36 Figure 8 : Trends of Syphilis Prevalence among Transgenders by Locations, 2007-2013

  37 Figure 9 : Trends of HIV Prevalence among DFSW by Locations, 2007-2013

  38 Figure 10 : Trends of Syphilis Prevalence among DFSW by Locations, 2007-2013

  38 Figure 11 : Correlation between HIV and Syphilis Prevalence among DFSW, MSM, and Transgenders, SSS 2013

  39 List of Figures List of Abbreviations

  AIDS : Acquired Immune Deficiency Syndrome CIS : Cluster Information System DFSW : Direct Female Sex Workers FSW : Female sex workers HIV : Human Immunodeficiency Virus HRM : High Risk Men

  IBBS : Integrated Biological Behavioral Survey

  IFSW : Indirect Female Sex Worker MOH : Ministry of Health MSM : Men who have sex with men NAC : National AIDS Commission NGO : Non-Governmental Organization PWID : People Who Inject Drugs RBS : Rapid Behavioral Survey RDS : Respondent Driven Sampling vey PPS : Probability Proportional to Size RPR : Rapid plasma reagin SSS : Sero-Surveillance Survey STI : Sexually Transmitted Infection TPHA : Treponema pallidum particule agglutination assay WHO : World Health Organization veillance And 2013 Rapid Behavioral Sur SRS : Simple Random Sampling

  Technical Report: 2013 Sero-Sentinel Sur

Chapter I: Introduction

1. Background

  Indonesia is facing one of the fast growing HIV epidemic in the Southeast Asia region. With an estimated half a million people believed to be infected by HIV in Indonesia[1]. Indonesia has both concentrated epidemic in the majority of its districts and a generalized epidemic in the Papua region[2]. Given the mortality and morbidity caused by the disease, it is very important to continuously monitor its burden in order to orient efficiently prevention and support programs and evaluate the response put in place to tackle the epidemic. Hence, the country has instituted HIV surveillance. This is a systematic data collection on HIV, followed by analysis, interpretation to collected data, and dissemination for utilization for HIV programs design, planning and for the evaluation of impacts in the community.

  Since 1988, Indonesia conducted HIV Sero-Surveillance Survey and Syphilis in two provinces, Jakarta and East Java to measure the burden and the trend of HIV and Syphilis distribution among sex workers. For more representativeness of the HIV surveillance, the number of provinces and districts participating in HIV surveillance and the target groups increased over the years. Since then, HIV prevalence surveillance was conducted as sentinel surveillance or as ad hoc exercises. Other key populations including men who have sex with men (MSM), direct female commercial sex workers (DFSW), indirect female sex workers (IDFSW), people who inject drug (PWID), transgenders and other high risk populations who are at risk of getting HIV due to their occupations such as fishermen, truck drivers (called high risk men (HRM) were included.

  From 1996, a surveillance of risky behaviors exposing individuals to HIV was instituted. vey This was followed by the adoption of the report on the second generation of HIV surveillance[3] and the HIV surveillance system in Indonesia included HIV prevalence, risky behaviors and knowledge about HIV prevention and HIV program coverages. In 2007, for the first time, Indonesia conducted its first integrated biological and behavioral survey(IBBS)[1], which was followed by two other rounds in 2011[2] in the same geographical areas. However, given the large size of the country and logistic challenges to conduct the integrated biological and behavioral survey across the country at once,

  IBBS was conducted in two groups of provinces in two different waves of surveys. veillance And 2013 Rapid Behavioral Sur The survey also included the measurement of sexually transmitted infections (STIs) as STIs increases the transmission of HIV [4]. Therefore, an increase in STIs may indicate a potential risk of increased HIV prevalence.

  HIV prevalence has been high in some key populations in most of the districts in Indonesia except in Papua region where the infection has reached the general population The 2000 Sentinel Surveillance showed that HIV prevalence among the Technical Report: 2013 Sero-Sentinel Sur female sex workers (FSW) was greater than 5% in several locations. It was even higher STIs prevalence remains high among sexual active and other adult key populations in Indonesia. The 2011 Integrated Biological and Behavior Survey indicated that prevalence of gonorrhea in several locations was between 19% and 38%, the prevalence of chlamydia ranged between 21% and 41%, syphilis was found among 2% and 10% of tested adults. It also showed that HIV prevalence was between 0.7% and 41% and both gonorrhea and or chlamydia were concomitantly found among 33% to 56% of tested adults[2]. STIs prevalence may also reflect condom use behavior. An increasing condom use will reduce STIs’ incidence and prevalence, and if sustained, it can also have an impact on the reduction of HIV prevalence with time. The STIs prevalence is also able to inform on the coverage and quality of the STI control program. Therefore, given the higher prevalence of STIs among key populations and the great concern that the prevalence of HIV in Indonesia is increasing following the pattern of STIs distribution, a periodical data monitoring of STI prevalence as part of HIV surveillance is needed, to see the trend of sexual behavior, and the potential of HIV transmission [4]. STI’ surveillance may serve as a tool for monitoring, evaluation, and planning of STI and HIV and AIDS control program.

  With the introduction of the second generation of HIV surveillance approach, Indonesia started monitoring risky behaviors among key populations. In 2010, the national AIDS commission, in collaboration with different partners and local authorities, conducted the first rapid behavioral survey among PWID and female commercial sex workers. PWID were surveyed in 8 cities (Medan, Palembang, DKI Jakarta, Bandung, Semarang, Surabaya, Denpasar, Makassar) and were recruited from 10 cities (Bintan, Palembang, Jakarta Barat, Semarang City, Malang, Banyuwangi, Denpasar, Makassar, Jayapura and Sorong City) respectively. This survey showed that vey 73% PWID did not share needles at their last injection, 63% of them did not share needles in their last week injections, 61% of them did not share needles in the last moth injections and 35% did not share needles during injections in the past last year prior to the survey[5, 6]. To have a solid trend data on HIV, another IBBS in 2014 will be conducted in the same locations of IBBS 2011. A Sero-Surveillance Survey and Rapid Behavior Survey were conducted in 2013 in the same locations as the IBBS 2011 to provide data for the planning veillance And 2013 Rapid Behavioral Sur these activities did not measure the prevalence of gonorrhea and chlamydia. The 2013 of both the MOH and NAC HIV/AIDS strategic plans. However, unlike in the 2011 IBBS, SSS measured HIV and syphilis prevalence and the 2013 RBS assessed the prevalence of risk behavior among key populations. The 2013 was conducted in collaboration with the National AIDS Commission.

  Technical Report: 2013 Sero-Sentinel Sur

  2. Scope

  This report aimed to provide data to assess the impact of the national response to the HIV epidemic. It aims at:

  ƒ

  Determining the prevalence of HIV and syphilis among key affected populations in twenty-three districts/cities in Indonesia in 2013.

  ƒ

  Determining the trends of the prevalence of HIV and syphilis among key affected populations in twenty-two districts/cities in Indonesia by comparing these results with the 2007 and 2011 IBBS, and 2013 Sero-Surveillance Survey.

  ƒ

  Determine trends in the level of selected HIV related risk behaviors among key affected populations in twenty-two districts/cities in Indonesia and comparing them with the 2007 IBBS and 2011 IBBS.

  3. Outcomes

  The report provides information about the following indicators for the locations and cities surveyed:

  1. Prevalence of HIV among PWIDs, MSM, transgenders and direct FSW

  2. Prevalence of syphilis among PWIDs, MSM, transgenders and direct FSW

  3. Number of DFSW’s clients per week

  4. Proportion of DFSW who used condom during the last commercial sex

  5. Proportion of DSFW who used condoms in commercial sex the last week

  6. Proportion of MSM who ever injected drug vey

  7. Proportion of MSM who used condom at their last commercial sex

  8. Proportion of PWIDs who ever tested for HIV

  9. Proportion of PWIDs sharing needle during injection last month

  10. Proportion of PWIDs not sharing needle during the last injection veillance And 2013 Rapid Behavioral Sur

  Technical Report: 2013 Sero-Sentinel Sur

Chapter II: Methodology

2.1. Sero-Surveillance Survey

  The Sero-Surveillance Survey was a cross-sectional, using a two-stage sampling techniques. It was conducted from July to October 2013 in 22 cities/districts from 11 provinces. For the Sero-Surveillance Survey DFSW were recruited form 16 cites, PWID were recruited from five cities, transgenders were from four cities, and MSM were recruited from four cities (Table 2). The population for the Sero-Surveillance Survey included direct female sex workers, people who inject drugs, transgenders and men who have sex with men. The participants for the Sero-Surveillance Survey wererecruited from multiple sites, including community health centers, hotspots, support groups and community based organizations.

2.1.1. Selection criteria

  To be included in the study, participants should have been identified to one of the key population definitions below:

  ƒ

  Direct female sex worker (DFSW) - a woman who operates openly as a commercial sex worker;

  ƒ

  Transgenders are biologically males but behave and feel like women. Transgenders in this 2013 Sero-Surveillance Survey are not only sex workers but also include those who work in salons;

  ƒ vey Men who have sex with men includes men who consider themselves as gay or those who do not but have sex with men and includes men who are bisexual as well as

  homosexual;

  ƒ

  People who inject drugs are people who inject drugs or have a history of injecting drugs in the last 1 year. veillance And 2013 Rapid Behavioral Sur

2.1.1.1. Sampling

  During the sampling of DFSW and transgenders, the first stage consisted into selecting sample at the survey sites by using the Cluster Information Sheet (CIS) application according to the decided sampling framework. The CIS application was used to perform the sample selection at the survey sites using Probability Proportional to Size (PPS), with the ‘size’ being the size of the population group in each location. During the second stage, the sample (respondents) was used to meet the planned sample Technical Report: 2013 Sero-Sentinel Sur selection at the survey sites using Probability Proportional to Size (PPS), with the size being the size of the population group in each location.

  The respondents driven sampling was used for mobile and hard to find key populations such as MSM and PWID. This sampling method was used because behavior in which these subpopulations engaged in is illegal or stigmatized. A total of eight participants were selected by the surveyors and recruited as seeds. These seeds recruited the next wave of participants who also went on to recruit each three (3) other participants using the snowball technique until the end of the recruiting period.

  For the Sero-Surveillance Survey, the sample size for each key population was 250 per surveyed site. The total sample size planned for DFSW, PWID, MSM and transgenders was eight thousand participants.

  2.1.2. Biological testing and quality assurance Blood was collected by venipuncture from consenting key population participants.

  All surveyors were trained to collect and handle specimen accordingly to the national standard procedures. Laboratory technicians were also trained in performing correctly HIV and syphilis tests. All collected specimens were sent to the provincial laboratories designated by the Ministry of Health. HIV tests were performed using Focus (R1) and Oncoprobe (R2) HIV 1 & 2 Antibody Rapid Test reagents following the MOH national HIV testing algorithm for HIV surveillance. Syphilis test used Rapid SD (TPHA) and RPR Shield (RPR).

  All laboratories had an internal and external quality assurance system in place to ensure the validity of the test result.

  2.1.3. Locations

  Both the 2013 Sero-surveillance Survey and Rapid Behavioral Survey (RBS) recruited vey participants from the 22 cities/districts in 11 provinces listed below:

  Table 1: List of provinces, districts/cities and the number of the participating sites Number of Provinces Cities and districts Locations

  1

  2 Sumatera Utara City of Medan, district of Deli Serdang veillance And 2013 Rapid Behavioral Sur

  2

  1 Kepulauan Riau City of Batam City of Bandar Lampung, district of Lampung

  3

2 Lampung

  1 Selatan City of Jakarta Barat, Jakarta Timur, Jakarta

  5 Utara, Jakarta Selatan, Jakarta Pusat

  4 DKI Jakarta

  11

  5 Jawa Barat City of Bandung Technical Report: 2013 Sero-Sentinel Sur

  Number of Provinces Cities and districts Locations 2,3

  2

  

6 Jawa Tengah City of Semarang, district of Batang

City of Surabaya,2,3 Malang, 2district of

  3

  7 Jawa Timur

2

Banyuwangi

  1

  8 Bali City of Denpasar

  9

  1 Nusa Tenggara Timur City of Kupang

  10

  1 Maluku City of Ambon City of Jayapura, district of Jayapura, and

  11

  3 Papua Jayawijaya.

2.2. Rapid Behavioral Survey

  2.2.1. Sample size

  The sample size for each risk sub population was determined accordingly to the WHO recommendation and the National Guideline of Second Generation HIV Surveillance of 2013. These recommend a selection of 30 clusters of seven respondents in each location. To account for data quality and none response, the sample size was fixed at 240 respondents per each risk group in each selected location (city or district). This is generally sufficient enough to be fairly a uniform distribution of the key population of interest as per WHO recommendation. The total sample size key population and location is provided below (Table 2). vey

  2.2.2. Tools

  A structured questionnaire was used to collect behavioral data on injecting and sexual behaviors between MSM and DFSW. Surveyors were trained to conduct interview and record participants ‘responses in the questionnaire. PWID were not included in the 2013 Rapid Behavioral Survey.

2.3. Implementation

  veillance And 2013 Rapid Behavioral Sur Surveyors were from MOH (Sub directorate AIDS & STI), Provincial Health Offices, District and City Health Offices, provincial laboratories units and Health Centers in different survey locations. Supervision was ensured by staffs from the national level.

  In Denpasar, the survey was additionally supported by, a local non-governmental organization (NGO) and by WHO. The Clinton Foundation supported the implementation in Jayapura and Jayawijaya Papua. 1 Technical Report: 2013 Sero-Sentinel Sur 2 PWID and MSM were recruited form for both 2013 SS and 2013 Rapid Behavioral survey 3 DFSW were recruited from here for both 2013 SS and 2013 Rapid Behavioral survey

2.4. Analysis

  Univariate analysis was conducted at location level only for both biological and behavioral data to determine prevalence of HIV and syphilis among different key populations and the frequency of risk behaviors among DFSW, PWID, and MSM. A chi square test was used to compare observed data in 2013 Sero-Surveillance Survey to the 2011 Integrated Biological and Behavioral Survey results. This test was also used to determine the trends within same locations having data for 2007-2013. These analyses concerned only DFSW, PWID, MSM, and transgenders.

  Limitations

  The behavioral data and the biological data from the 2013 Sero-Surveillance Survey could not be linked at individual level due to some technical reasons, making any association between HIV and syphilis prevalence and risk behaviors difficult. Only indirect inference can be made from the data in this report.

  Comparison of data of HIV and syphilis prevalence at location level should be interpreted with caution as the disaggregation at that level yielded small numbers. Limitations inherent to sampling methods are not excluded from this study. The multi- stage sampling method used for transgenders and direct female sex workers may not reflect the diversity of the community from where the sample came. It may provide less information per observation than a simple random sampling (SRS) of the same size (redundant information: similar information from the others in the cluster) and the standard errors of the estimates may be high, compared to other sampling designs with same sample size. On the other hand, the respondent driven sampling used for MSM and PWID may not vey overcome the coverage and non-response error which it is intended to avoid.

  veillance And 2013 Rapid Behavioral Sur Technical Report: 2013 Sero-Sentinel Sur

Chapter III: Results

3.1. Results of the 2013 HIV Sero-Surveillance Survey

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey

  

240

Malang 250 249 203 240 Surabaya

   Sample size attained Total

3685

4 985 978 960

  Jayapura

114

Jayawijaya

331

  East NT Kupang

110

Maluku Ambon 225 Papua

  240 244 240 240 Bali Denpasar

400

  Semarang

244

East Java Banyuwangi

  3.1.1. Participation rate Table 2: Planned Sample Size and Sampling Method by Target Population and Location

  240 240 West Java Bandung 250 247 240 240 Central Java Batang 255

  55 Lampung Lampung 250 Riau Island Batam 286 DKI Jakarta Jakarta Utara 240 245

  Deli Serdang 250 Medan

  1250 1000 % Participation Rate 92% 99% 78% 96% North Sumatra

  Respondents driven sampling Target Sample (n) 4000 1000

  Province City DFSW Transgenders PWID MSM Multistage sampling proportional to size

  Of the planned sample sizes, the survey participation rate was 92% for DFSW, 78% for PWID, 99% for transgenders and 96% for MSM.

4 Specimens from Kupang were not tested for syphilis

  3.1.2. Characteristics of the Population Groups

  A total of 6603 participants were recruited for the 2013 SSS. Of those, 3685 were DFSW, 985 were transgenders, 978 were PWID, and 985 were MSM. In the 2013 SSS, direct female sex workers represented 55.8%of participants, PWID and transgenders represented each 14.8%, and MSM represented 14.5% of participants. The distribution of all key populations by location was as followed: 14% were from Malang, 15% from Surabaya, 15% from Jakarta and 15% from Bandung. All the other locations had less than 7% of the participants.

  3.1.3. HIV prevalence

  3.1.3.1. HIV prevalence among different key population Table 3: Prevalence of HIV and Syphilis per Target Group of Key Affected Populations in the Sero-Surveillance Survey 2013 HIV Prevalence Syphilis Prevalence Target Syphilis N HIV +(n) N % HIV (95% CI) Group

  Positive (n) %Syphilis (95% CI) PWID 978 435 44.5 (41.4-47.6) 978 16 1.6 (0.8-2.4) 122 MSM 960 166 17.3 (14.9-19.7) 960 12.7 (10.6-14.8) Transgender 980 186 19 (16.5-21.5) 980 159 16.2 (13.9-18.5)

  10 (9-11) 202 Direct FSW 3685 367 3575 5.7 (4.9-6.5) Total 6603 499 7.7 (7-8.3) 1154 17.5 (16.6-18.4) 6493 vey

  From the key populations surveyed in the 2013 Sero-Surveillance Survey, HIV prevalence was highest among the PWIDs with 44.5%. They were followed by transgenders with 19%, MSM with 17.3% and DFSW with 10% (Table 3).

3.1.3.2. HIV prevalence among PWID Among PWID, HIV prevalence ranged between 27.1% in Bandung to 59.1% in Malang.

  veillance And 2013 Rapid Behavioral Sur This prevalence was 27.3% in Medan, 48.8% in Surabaya and 49.2% in Jakarta (Table 4).

  Technical Report: 2013 Sero-Sentinel Sur Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey Table 4: HIV Prevalence among PWID per Location in IBBS 2011 and Sero-Surveillance Survey 2013

  The Sero-Surveillance Survey results showed, in table 5, that HIV prevalence among MSM was highest in Surabaya with 22.1% followed by Bandung (21.3%), Jakarta (19.6%) and lastly by Malang (6.3%).

  PWID HIV Prevalence (%) of IBBS 2011 in all location HIV Prevalence (%) of IBBS 2011 in same locations as for SSS 2013 HIV Prevalence (%) of SSS 2013 Comparison Location N % HIV (95% CI) N % HIV (95% CI) N % HIV (95% CI) P-value comparing same location IBBS 2011 and SS 2013 OR (CI 95%)

  HIV Prevalence in same locations IBBS 2011 vs. SS 2013

  Medan 250 39.2(33.1-45.3) 250 39.2(33.1-45.3) 55 27.3(15.5-39.1) 0.132 1.72 (0.9-3.28) Jakarta 250 56.4(50.3-62.5) 250 56.4(50.3-62.5) 240 49.2(42.9-55.5) 0.13 1.34 (0.94-1.91) Bandung 250 25.2(19.8-30.6) 250 25.2(19.8-30.6) 240 27.1(21.5-32.7) 0.138 0.91 (0.61-1.36) Semarang 169 1.2(-0.4-2.8) Malang 250 36.4(30.4-42.4) 250 36.4(30.4-42.4) 203 59.1(52.3-65.9) 0.000003 0.4 (0.27-0.58) Surabaya 250 48.8(42.6-55) 250 48.8(42.6-55) 240 48.8(42.5-55.1) 0.94 1 (0.7-1.43) Total* 1419 36.4(33.9-38.9)

  1250 41.2(38.5-43.9) 978 44.5(41.4-47.6) 0.13 0.87 (0.74-1.04) PWID HIV Prevalence (%) of IBBS 2011 in all location HIV Prevalence (%) of IBBS 2011 in same locations as for SSS 2013 HIV Prevalence (%) of SSS 2013 Comparison

  Location N % HIV (95% CI) N % HIV (95% CI) N % HIV (95% CI) P-value comparing same location IBBS 2011 and SS 2013 OR (CI 95%)

  HIV Prevalence in same locations IBBS 2011 vs. SS 2013

  Medan 250 39.2(33.1-45.3) 250 39.2(33.1-45.3) 55 27.3(15.5-39.1) 0.132 1.72 (0.9-3.28) Jakarta 250 56.4(50.3-62.5) 250 56.4(50.3-62.5) 240 49.2(42.9-55.5) 0.13 1.34 (0.94-1.91) Bandung 250 25.2(19.8-30.6) 250 25.2(19.8-30.6) 240 27.1(21.5-32.7) 0.138 0.91 (0.61-1.36) Semarang 169 1.2(-0.4-2.8) Malang 250 36.4(30.4-42.4) 250 36.4(30.4-42.4) 203 59.1(52.3-65.9) 0.000003 0.4 (0.27-0.58) Surabaya 250 48.8(42.6-55) 250 48.8(42.6-55) 240 48.8(42.5-55.1) 0.94 1 (0.7-1.43) Total* 1419 36.4(33.9-38.9)

  1250 41.2(38.5-43.9) 978 44.5(41.4-47.6) 0.13 0.87 (0.74-1.04)

3.1.3.3. HIV Prevalence among MSM

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey Table 5: HIV Prevalence among the MSM per Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013

  Jakarta had the highest HIV prevalence among Transgenders with 29.6% followed by Surabaya with 27.5%, Bandung and Malang with 9.6% and 9.2% respectively (Table 6).

  MSM HIV Prevalence (%) of IBBS 2011 in all location HIV Prevalence (%) of IBBS 2011 in same locations as for SSS 2013 HIV Prevalence (%) of SSS 2013 Comparison Location N % HIV (95% CI) N % HIV (95% CI) N P-value comparing same location IBBS 2011 and 2013 OR (CI 95%)

  HIV Prevalence in same locations IBBS 2011 vs. SSS 2013

  Jakarta 250 17.2 (12.5-21.9) 250 17.2 (12.5-21.9) 240 19.6 (14.6-24.6) 0.57 0.85 (0.54-1.35) Bandung 250 10.4 (6.6-14.2) 250 10.4 (6.6-14.2) 240 21.3 (16.1-26.5) 0.001 0.43 (0.26-0.72) Semarang 249 0 (0-0) Malang 247 2.5 (0.6-4.4) 247 2.5 (0.6-4.4) 240 6.3 (3.2-9.4) 0.64 0.37 (0.14-0.98) Surabaya 248 9.6 (5.9-13.3) 248 9.6 (5.9-13.3) 240 22.1 (16.9-27.3) 0.00028 0.38 (0.22-0.06) Total* 1244 8 (6.5-9.5) 995 9.9 (8-11.8) 960 17.3 (14.9-19.7) 0.000002 0.53 (0.4-0.69)

3.1.3.4. HIV prevalence among transgenders

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey Transgender HIV Prevalence (%) of IBBS 2011 in all location HIV Prevalence (%) of IBBS 2011 in same locations as for SSS 2013 HIV Prevalence (%) of SSS 2013 Comparison

  Location N % HIV (95% CI) N % HIV (95% CI) N % HIV (95% CI) P-value comparing same location IBBS 2011 and 2013 OR (CI 95%)

  HIV Prevalence in same locations IBBS 2011 vs. SSS 2013

  Jakarta 245 30.8(25-36.6) 245 30.8(25-36.6) 250 29.6(23.9-35.3) 0.88 1.05(0.71-1.54) Bandung 247 14.4(10-18.8) 247 14.4(10-18.8) 250 9.6(5.9-13.3) 0.12 1.61(0.93-2.78) Semarang 87 24.7(15.6-33.8) Malang 249 16.8(12.2-21.4) 249 16.8(12.2-21.4) 240 9.2(5.5-12.9) 0.017 2.01(1.16-3.48) Surabaya 244 24.4(19-29.8) 244 24.4(19-29.8) 240 27.5(21.9-33.1) 0.53 0.86(0.57-1.29) Total 1072 21.8(19.3-24.3)

  985 21.6(19-24.2) 980 19(16.5-21.5) 0.178 1.17(0.94-1.46)

  From the 2013 HIV and Syphilis Sero-Surveillance Survey, HIV prevalence among direct female sex workers spanned between 32.5%, the highest prevalence found in Jayawijaya, and 1.6%, the lowest found in Deli Serdang. Denpasar had 20.3% HIV prevalence. Jayapura, Ambon, and Surabaya were the other three districts with an HIV prevalence above 10% among DFSW (Table 7).

  Table 5: HIV Prevalence among the MSM per Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013

3.1.3.5. HIV prevalence among DFSW

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey HIV Prevalence (%) of IBBS 2011 in all location HIV Prevalence (%) of IBBS 2011 in same locations as for SSS 2013 HIV Prevalence (%) of SSS 2013 Comparison

  DFSW N % HIV (95% CI) IBBS 2011 in all location N % HIV (95% CI) of IBBS 2011 in same locations as for SSS 2013 N

  % HIV (95% CI) of SSS 2013 P-value comparing same location IBBS 2011 and 2013 OR (CI 95%) HIV

  Prevalence in same locations IBBS 2011 vs. SSS 2013 Deli Serdang 247 3.6(1.3-5.9) 247 3.6(1.3-5.9) 250 1.6(0-3.2) 0.25 2.33(0.71-7.65) Lampung 248 5.6(2.7-8.5) 248 5.6(2.7-8.5) 250 5.2(2.4-8) 0.98 1.09(0.5-2.37) Batam 249 10(6.3-13.7) 249 10(6.3-13.7) 286 8(4.9-11.1) 0.51 1.28(0.7-2.3) Jakarta Utara 248 10.5(6.7-14.3) 248 10.5(6.7-14.3) 240 3.8(1.4-6.2) 0.0046 3(1.38-6.56) Bekasi 245 6.8(3.6-10)

  Bandung 250 11.6(7.6-15.6) 250 11.6(7.6-15.6) 250 8(4.6-11.4) 0.23 1.5(0.83-2.75) Batang 178 20.7(14.7-26.7) 178 20.7(14.7-26.7) 255 9.4(5.8-13) 0.0013 2.53(1.45-4.4) Semarang 249 4.8(2.1-7.5) 249 4.8(2.1-7.5) 244 2.5(0.5-4.5) 0.25 2(0.74-5.44) Banyuwangi 251 7.2(4-10.4) 251 7.2(4-10.4) 240 9.6(5.9-13.3) 0.42 0.73(0.38-1.39) Malang 249 4(1.6-6.4) 249 4(1.6-6.4) 250 4.4(1.9-6.9) 0.99 0.91(0.38-2.18) Surabaya 249 10.4(6.6-14.2) 249 10.4(6.6-14.2) 240 12.5(8.3-16.7) 0.33 0.82(0.47-1.43)

  Denpasar 248 16(11.4-20.6) 248 16(11.4-20.6) 400 20.3(16.4-24.2) 1.45 0.76(0.5-1.15) Kupang 249 8.8(5.3-12.3) 249 8.8(5.3-12.3) 110 5.5(1.2-9.7) 0.37 1.68(0.66-4.27) Ambon 198 12.3(7.7-16.9) 198 12.3(7.7-16.9) 225 13.3(8.9-17.7) 0.05 0.9(0.5-1.59)

  Jayawijaya 187 25(18.8-31.2) 187 25(18.8-31.2) 114 32.5(23.9-41.1) 0.21 0.7(0.41-1.17) Jayapura 248 16(11.4-20.6) 248 16(11.4-20.6) 331 15.1(11.2-19) 0.83 1.08(0.69-1.7) Total 3793 10.4(9.4-11.4) 3548 10.6(9.6-11.6) 3685 10(9-10.97) 0.35 1.08(0.93-1.25) Table 7: HIV Prevalence of DFSW per location in IBBS 2011 and Sero-Surveillance Survey 2013

3.1.4. Prevalence of syphilis

  3.1.4.1. Syphilis prevalence among different key population

  The 2013 HIV and Syphilis Sero-Surveillance Survey showed that the overall syphilis prevalence was 6.6 % among all the participants. The syphilis prevalence was highest among transgenders (16.2%), followed by MSM (12.7%) and direct female sex workers (5.5%) (Table3).

  3.1.4.2. Prevalence of Syphilis among PWID

  Among PWID, the highest syphilis prevalence was recorded in Medan at 7.3%, followed by Jakarta with a rate of 3.8% and Bandung with 1.3%. Malang and Surabaya did not register any case of syphilis in the survey (Table 8).

  Table 8: Prevalence of Syphilis among PWID per Location in IBBS 2011 and Sero-Surveillance Survey 2013 P-value Prevalence Syphilis Syphilis Syphilis same comparing Prevalence in OR (CI 95%) syphilis Location N N Prevalence % N Prevalence % location % (CI 95%) IBBS 2011 same locations 2011 (CI 95%) (CI 95%) and 2013 SSS IBBS 2011 vs. 2013SSS

  Medan 250 5.6(2.7-8.5) 250 5.6(2.7-8.5) 55 7.3(0.4-14.2) 0.87 0.76(0.24-2.39) vey Jakarta 250 4.4(1.9-6.9) 250 4.4(1.9-6.9) 240 3.8(1.4-6.2) 0.89 1.18(0.48-2.9) 0.4(-0.4-1.2) 0.4(-0.4-1.2) 240 Bandung 250 250 1.3(0-2.7) 0.59 0.32(0.03-3.07) Semarang 169 0.6(-0.6-1.8) Surabaya 0.4(-0.4-1.2) 0.4(-0.4-1.2) 240 0(0-0) Malang 250 0.8(-0.3-1.9) 250 0.8(-0.3-1.9) 203 0(0-0) 0.98

  0.57 veillance And 2013 Rapid Behavioral Sur Total* 1419 2.1(1.4-2.8) 1250 2.3(1.5-3.1) 978 1.7(0.9-2.5) 0.32 1.43(0.77-2.6) 250 250

  3.1.4.3. Prevalence of syphilis among MSM

  Syphilis prevalence was highest among MSM in Bandung at 15.4% followed by Surabaya and Jakarta with 14.6% and 14.2% respectively. In Malang, syphilis prevalence among Technical Report: 2013 Sero-Sentinel Sur MSM was 6.7% (Table 9).

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey Table 9: Prevalence of Syphilis among the MSM per Location in IBBS 2011 and in Sero- Surveillance Survey (SS) 2013

  Among transgenders, Jakarta had the highest syphilis prevalence with 29.2%, followed by Surabaya with 17.1%, Bandung with 14% and Malang was last with 4,2% (Table 10 ).

  MSM Syphilis Prevalence (%) of IBBS 2011 in all location Syphilis Prevalence (%) of same location of IBBS 2011 in Sero-Surveillance Survey Syphilis Prevalence (%) in all 2013 Sero- Surveillance Survey Location Comparison Location N Syphilis

  Prevalence % (CI 95%) N Syphilis

  Prevalence % (CI 95%) N Syphilis

  Prevalence % (CI 95%) P-value comparing same location IBBS 2011 and 2013 SSS OR (CI 95%) syphilis Prevalence in same locations IBBS 2011 vs. 2013 SSS

  Jakarta 250 16.8(12.2-21.4) 250 16.8(12.2-21.4) 240 14.2(9.8-18.6) 0.5 1.22(0.75-2) Bandung 250 11.2(7.3-15.1) 250 11.2(7.3-15.1) 240 15.4(10.8-20) 0.21 0.69(0.41-1.17) Malang 247 3.4(1.1-5.7) 247 3.4(1.1-5.7) 240 6.7(3.5-9.9) 0.12 0.47(0.2-1.12) Surabaya 248 9.6(5.9-13.3) 248 9.6(5.9-13.3) 240 14.6(10.1-19.1) 0.13 0.63(0.336-1.09) Total* 1244 8.2(6.7-9.7) 995 10.3(8.4-12.2) 960 12.7(10.6-14.8) 0.1 0.78(0.59-1.04)

3.1.4.4. Prevalence of syphilis among transgenders

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey Transgender Syphilis Prevalence (%) of IBBS 2011 in all location Syphilis Prevalence (%) of same location of IBBS 2011 in Sero- Surveillance Survey Syphilis Prevalence (%) in all 2013 Sero- Surveillance Survey Location Comparison

  Location N Syphilis Prevalence% (CI95%)

  N Syphilis Prevalence% (CI95%)

  N Syphilis Prevalence% (CI95%)

  P-value comparing same location IBBS 2011 and 2013 OR (CI 95%) syphilis Prevalence in same locations IBBS 2011 vs. SSS 2013

  Jakarta 245 31.2(25.4-37) 245 31.2(25.4-37) 250 29.2(23.6-34.8) 0.73 1.09(0.74-1.6) Bandung 247 26.4(20.9-31.9) 247 26.4(20.9-31.9) 250 14(9.7-18.3) 0.0009 2.19(1.39-3.46) Semarang 87 0(0-0) Malang 249 20.8(15.8-25.8) 249 20.8(15.8-25.8) 240 4.2(1.7-6.7) 0.00000006 6.07(3-12.26) Surabaya 244 25.2(19.8-30.6) 244 25.2(19.8-30.6) 240 17.1(12.3-21.9) 0.43 1.62(1.04-2.52) Total 1072 23.8(21.3-26.3)

  985 25.9(23.2-28.6) 980 16.2(13.9-18.5) 0.0000002 1.8(1.45-2.25) Table 10: Prevalence of Syphilis among the Transgenders by Location in IBBS 2011 and in Sero- Surveillance Survey (SS) 2013

3.1.4.5. Prevalence of syphilis among DFSW

  Syphilis prevalence among DFSW was highest in Jayawijaya (33.3%), followed by Ambon (10.2%), Denpasar (7.3%) and Malang and Lampung (6.8% and 6.4% in respectively). The lowest syphilis among DFSW was recorded in Batang (1.2%) as noted in table 11.

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey DFSW Syphilis Prevalence (%) of IBBS 2011 in all location Syphilis Prevalence (%) of same location of IBBS 2011 in Sero- Surveillance Survey Syphilis Prevalence (%) in all 2013 Sero-Surveillance Survey Location Comparison

  Location N Syphilis Prevalence% (CI95%)

  N Syphilis Prevalence% (CI95%)

  N Syphilis Prevalence% (CI95%)

  P-value comparing same location IBBS 2011 and 2013 OR (CI 95%) syphilis Prevalence in same locations IBBS 2011 vs. SSS 2013

  Deli Serdang 247 16.6(12-21.2) 247 16.6(12-21.2) 250 4.8(2.2-7.4) 0.000033 0.42(0.28-0.63) Lampung 248 9.2(5.6-12.8) 248 9.2(5.6-12.8) 250 6.4(3.4-9.4) 0.3 1.5(0.77-2.9) Batam 249 11.6(7.6-15.6) 249 11.6(7.6-15.6) 286 3.8(1.6-6) 0.0011 3.3(1.61-6.75) Jakarta Utara 248 4.8(2.1-7.5) 248 4.8(2.1-7.5) 240 2.5(0.5-4.5) 0.26 1.98(0.73-5.3) Bekasi 245 15.2(10.7-19.7)

  Bandung 250 10.4(6.6-14.2) 250 10.4(6.6-14.2) 250 2.8(0.8-4.8) 0.0011 4.03(1.72-9.47) Batang 178 13.4(8.4-18.4) 178 13.4(8.4-18.4) 255 1.2(-0.1-2.5) 0.00000005 13.1(3.88-44.2) Semarang 249 0.8(-0.3-1.9) 249 0.8(-0.3-1.9) 244 2.9(0.8-5) 0.17 0.27(0.06-1.33) Banyuwangi 251 8.8(5.3-12.3) 251 8.8(5.3-12.3) 240 5.8(2.8-8.8)

  0.28 1.55(0.77-3.11) Malang 249 7.2(4-10.4) 249 7.2(4-10.4) 250 6.8(3.7-9.9) 0.99 1.07(0.54-2.12) Surabaya 249 12.4(8.3-16.5) 249 12.4(8.3-16.5) 240 4.6(1.9-7.3) 0.003 2.96(1.45-6.04) Denpasar 248 4.4(1.8-7) 248 4.4(1.8-7) 400 7.3(4.8-9.8) 0.2 0.59(0.29-1.21) Kupang 249 10(6.3-13.7) Ambon 5 198 5.2(2.1-8.3) 198 5.2(2.1-8.3) 225 10.2(6.2-14.2) 0.048 0.47(0.22-1) Jayawijaya 187 31.4(24.7-38.1) 187 31.4(24.7-38.1) 114 33.3(24.6-42)

  0.75 0.92(0.56-1.52) Jayapura 248 6(3-9) 248 6(3-9) 331 2.4(0.7-4.1) 0.027 2.6(1.08-6.23) Total 3793 10.1(9.1-11.1) 3299 9.8(8.8-10.8) 3575 5.7(4.9-6.4) <0.0001 1.87(1.56-2.24)

  Table 11: Prevalence of Syphilis among the DFSW by Location in IBBS 2011 and in Sero- Surveillance Survey (SS) 2013

5 Specimens were not tested for syphilis in Kupang

3.1.5. Comparison between HIV and syphilis prevalence between 2011 Integrated Biological and Behavioral Survey and 2013 Sero-Surveillance Survey

  When compared to the 2011 IBBS, and including only the districts which participated in the 2011 integrated biological and behavioral survey, HIV prevalence among the MSM increased significantly from 10.6% to 17.3% [p< 0.000002, OR=0.56 (0.43-0.73)]. On the other hand there was a significant decrease in HIV prevalence among transgenders from 23.8% to 19% [p=0.01, OR=1.33 (1.07-1.65). The prevalence of HIV among PWID and among DFSW remained stable (the change was not statistically significant at 95% of confidence interval) between the two surveys (Table 12).

  Table 12: Comparing HIV prevalence among key population in the same locations for IBBS 2011 and Sero-Surveillance Survey 2013 HIV Prevalence (%) of IBBS 2011 in same HIV Prevalence (%) of Comparison

  IBBS 2013 locations as for IBBS 2013 P-value Target Group N N comparing same OR (CI 95%) HIV prevalence in % HIV (95% CI) % HIV (95% CI) same locations PWID locations IBBS 2011 and 2013 0.13 IBBS 2011 vs. IBBS 2013 vey Transgender 985 23.8(22.5-25.1) 980 19(17.8-20.2) MSM 995 10.6(9.6-11.6) 960 17.3(16.1-18.5) 0.000002 0.56(0.43-0.73) 1250 41.2(39.8-42.6) 978 44.5(42.9-46.1) 0.87(0.74-1.04) 0.01 1.33(1.07-1.65)

  Direct FSW 2864 9.4(8.9-9.9) 10(9-10.93) 0.44 0.94(0.8-1.1)

3685

  Comparing the 2011 Integrated Biological and Behavioral Survey to the 2013 Sero- Surveillance Survey , syphilis prevalence significantly declined from 27.5% to 16.2% among transgenders [p<0.000001, OR=1.96 (1.57-2.44)] and from 8.8% to 5% among veillance And 2013 Rapid Behavioral Sur DFSW [p<0.000001, OR=1.82(1.48-2.24)]. The prevalence of syphilis remained stable between the two surveys among PWID and MSM where no statically significant changes were observed (table 13).

  Technical Report: 2013 Sero-Sentinel Sur

  Table 13: Prevalence of Syphilis among PWID by Location, 2011-2013 P-value OR (CI 95%) HIV Syphilis Syphilis Syphilis Prevalence in comparing same

  Target Group N Prevalence% N Prevalence% N Prevalence% same locations location IBBS IBBS 2011 vs. PWID 1419 (CI95%) (CI95%) (CI95%) 2011 and 2013 0.32 SSS 2013 2.1(1.4-2.8) 1250 2.3(1.5-3.1) 978 1.6(0.8-2.4) 1.42(77-2.64) MSM 1244 12.7(10.6- 0.12 9.3(7.7-10.9) 995 10.3(8.4-12.2) 960 0.79(0.6-1.05)

  14.8) Transgender 16.2(13.9- 1072 25.3(22.7-27.9) 985 27.5(24.7-30.3) 980 < 0.000001 1.96(1.57-2.44) Direct FSW 10.2(9.2-11.2) 18.5) 3793 2864 8.8(7.8-9.8) 3575 5.7(4.9-6.4) < 0.000001 1.82(1.48-2.24)

  Except for Malang where HIV prevalence increased significantly from 36.4% to 59.1% [p<0.001, OR=0.4 (0.2 7-0.58)]; HIV prevalence among PWID remained stable between the 2011 Integrated Biological and Behavioral Survey and the 2013 HIVSero-Surveillance Survey (Table 4). Syphilis prevalence remained stable among PWID across all locations (Table 8) HIV prevalence among MSM increased in Bandung and in Surabaya from 10.4% to 21.3% [p=0.001, OR=0.43(0.26-0.72)] and from 10% to 17.3% [p<0.001, OR=0.53(0.4-0.69)]. There was no significant change of the syphilis prevalence among MSM across different locations between the two surveys (Tables 5-9).

  HIV prevalence among transgenders remained stable across all the locations (p>0.05) except in Malang where a significant decline was observed from 16.8% to 9.2% [p=0.017, OR=2.01(1.16-3.48)] (Table 6). Among the same key population, the prevalence of syphilis vey declined significantly in Bandung from 26.4% to 14% [p<0.001, OR=2.19(1.39-3.46)] and in Malang from 20.8% to 4.2% [p<0.001, OR=6.07(3-12.26)] (Table 10). HIV prevalence among DFSW significantly decreased in Jakarta and in Bandung from 10.5% to 3.8% [p=0.0046, OR=3(1.38-6.56)] and from 20.7% to 9.4% [p=0.0013, OR=2.53(1.45- 4.4) respectively. The other districts had their rate unchanged (Table 7). The overall syphilis prevalence among DFSW declined from 9.8% from the 2011 Integrated Biological and Behavioral Survey to 5.7% in the 2013 Sero-Surveillance Survey (Table 7). veillance And 2013 Rapid Behavioral Sur Syphilis prevalence among DFSW significantly declined in five of the 15 locations surveyed 6 in the 2013 Sero-Surveillance Survey compared to the 2011 IBBS . It decreased from 16.6% to 4.8% [p<0.05, OR 0.42(0.28-0.63)] in Deli Serdang. It also decreased from 11.6% to 3.3% [p=0.001, OR=3.3(1.5-6.75)] in Batam, from 10.4% to 2.8% [p<0.001, OR=4.03(1.7-9.72)] in Bandung; from 12.4% to 4.6% [p=0.003, OR=2.96(1.45-6.04)] in Surabaya and from 13.4% 6 to 1.2% [p<0.0001, OR=13.1(3.88-44.2)] in Batang (Table 11). Technical Report: 2013 Sero-Sentinel Sur

  Syphilis testing was conducted in Kupang

3.1.6. Trends analysis of HIV and syphilis prevalence among key populations between 2007 and 2013

3.1.6.1. Trends of HIV prevalence among Key Populations, 2007-2013

  The trends analysis showed that there has been a statistically significant decline of HIV prevalence of about 15% among PWIDs in the locations surveyed from 52.3% to 44.5% between 2007 and 2013. [p=0.00036, OR=0.729]. On the other hand, HIV prevalence increased steadily between 2007 and 2013 from 5% to 17.3%. This represented an increase of more than 200% from 2007.

  Figure 1: Trends of HIV Prevalence among Key Populations, 2007-2013 60% 50% 40% Trends of HIV Prevalence Among Key Populations, 2007-2013 10% 20% 30% 0% PWID MSM Transgender Direct FSW 2007 IBBS 2011 IBBS 2013 SS vey

  The analysis revealed that HIV prevalence among transgenders by 5% from its 24.4% level in 2007 to 19% in 2013. This represented 22% decrease from the 2007 HIV prevalence [p=0.00284, OR=0.726].

  veillance And 2013 Rapid Behavioral Sur Technical Report: 2013 Sero-Sentinel Sur

  3.1.6.2. Trends of HIV Prevalence among Key Populations by Location, 2007-2013

  Between 2007 and 2013, syphilis prevalence increased significantly among MSM from 1% to 12.7% [p=00001, OR=0.599]. However, the prevalence of syphilis declined among transgenders from 24.4% to 16.2% [p=0.00001, OR=0.599] and among DSFW from 6.2% to 5% [p=0.0317, OR=0.796].

  Figure 2: Trends of HIV Prevalence among Key Population by Location, 2007-2013 25.0% 30.0% Trends of Syphilis Prevalence Among Key Populations, 2007-2013 20.0% 10.0% 15.0% 5.0% 0.0%

PWID MSM Transgender Direct FSW

2007 IBBS 2011 IBBS 2013 SS 3.1.6.3.

   Trends of HIV Prevalence among PWIDs by Locations, 2007-2013

  3.1.6.3. Trends of HIV Prevalence among PWIDs by Locations, 2007-2013

  The trends data analysis showed that there has been a significant HIV prevalence decline among PWIDs in Medan from 2007 to 2015 as witnessed by the two surveys conducted in those years. Syphilis prevalence has dropped to half its original level in 2007. Bandung has also noted a significant decline of HIV prevalence among PWIDs between vey 2007 and 2013. HIV prevalence reduced by 37% from its original level of 42.8% to reach 27.1% in 2013 [p=0.00014, OR=0.496].

  Figure 3: Trends of HIV Prevalence among PWIDs by Locations, 2007-2013 80.0% 70.0% 60.0% 50.0% Trends of HIV Prevalence Among PWIDs by Locations, 2007-2013 veillance And 2013 Rapid Behavioral Sur 10.0% 20.0% 30.0% 40.0% 0.0% Medan Jakarta Bandung Malang* Surabaya 2007 IBBS 2011 IBBS 2013 SS Technical Report: 2013 Sero-Sentinel Sur

  

3.1.6.4. Trends of Syphilis Prevalence among PWIDs by Locations, 2007-2013

  The trends analysis revealed that the prevalence of syphilis increases significantly among PWIDs in Jakarta and Bandung from 0.1% to 3.8% [p=0.03, OR=9.86] and from 0% to 1.3% [p=0.033, OR=9.818].In Surabaya, syphilis prevalence remained stable among PWIDs between 2007 and 2013 [p=0.0457].

  Figure 4: Trends of Syphilis Prevalence among PWIDs by Locations, 2007-2013 10% 12% 14% 16% 4% 6% 2% 8% 0% Medan Jakarta Bandung Malang Surabaya Series1 Series2 Series3 vey

  3.1.6.5. Trends of HIV Prevalence among MSM by Locations, 2007-2013

  Data showed that HIV prevalence increased among MSM in Jakarta, Bandung and Surabaya from 8.1% to 19.6% [p=0.00031, OR=2.837], from 2% to 21.3% [p<0.00001, OR=13.22] and from 5.6% to 22.1% [p<0.00001, OR=4.778] respectively. veillance And 2013 Rapid Behavioral Sur Figure 5: Trends of HIV Prevalence among MSM by Locations, 2007-2013 % 30% Trends of HIV prevalence among MSM by Location, 2007-2013 ce n 20% el H IV Prev al 15% 10% 25% 5% Technical Report: 2013 Sero-Sentinel Sur 0% Jakarta Bandung Malang Surabaya 2007 IBBS 2011 IBBS 2013 SS

3.1.6.6. Trends of Syphilis Prevalence among MSM by Locations, 2007-2013

  The analysis showed that syphilis increased among MSM in Jakarta from 3.2% to 14.2% [p=0.00013, OR=5.055]; in Bandung from 5.6% to 15.4% [p=0.034, OR=2.129] and in Surabaya it increased from 4% to 14.6% [p=0.00008, OR=4.098]. Jakarta has the biggest increase of all the cities.

  Figure 6: Trends of Syphilis Prevalence among MSM by Locations, 2007-2013 25% al ence 15% % v re p 10% 20% Sy p h il is 0% 5%

Jakarta Bandung Malang Surabaya

2007 IBBS 2011 IBBS 2013 SS

  Compared to the starting prevalence level of 2007, Jakarta syphilis increased more than five folds. It was followed by Surabaya with four folds Bandung with two folds. There was no statistically significant change between the prevalence of syphilis among MSM in Malang between 2011 and 2013. vey

  3.1.6.7. Trends of HIV Prevalence among Transgenders by Locations, 2007-2013 Figure 7: Trends of HIV Prevalence among Transgenders by Locations, 2007-2013 40% 45% Trends of HIV Prevalvence among Transgenders by Location, 2007-2013 ce el 25% al n % 15% 20% 30% 35% veillance And 2013 Rapid Behavioral Sur H 10%

  IV Prev 0% 5%

Jakarta Bandung Malang Surabaya 2007 IBBS 2011 IBBS 2013 SS Technical Report: 2013 Sero-Sentinel Sur The trends analysis revealed that HIV prevalence declined significantly among DFSW in the following locations between 2007 and 2013: Deli Serdang; from 6.1% to 1.6% [p=0.00662, OR 0.254], Jakarta, from 10.2% to 3.8% [p=0.00654, OR=0.337] and in Semarang, from 6.6% to 2.5% [p=0.0229, OR=0.36. Between the same period, HIV prevalence increased in Surabaya from 6.5% to 12.5% [p=0.02754, OR=2.089] and in Denpasar from 14.1% to 20.3% [p=0.04, OR=1.56]. HIV prevalence remained stable in the remaining locations between 2007 and 2013 (Figure 9).

  3.1.6.8. Trends of Syphilis Prevalence among Transgenders by Locations, 2007-2013

  In figure 8, trends analysis of syphilis among transgenders showed that apart from Jakarta, Bandung, Malang, and Surabaya have noted significant declined of syphilis prevalence. The latter declined, between 2007 and 2013, from 25.2% to 14% in Bandung [p=0.00204, OR=.0483] and from 28.8% to 17.1% in Surabaya [p=0.00198, OR=.509]. In Malang, between 2007 and 2013, syphilis prevalence decreased from 20.8% to 4.2% [p<0.00001, OR=0.165].

  

Figure 8: Trends of Syphilis Prevalence among Transgenders by Locations, 2007-2013

35% 40% is p re il v al ence % 15% 25% 30% 20% vey 0% Sy p h 10% 5% Jakarta Bandung Malang Surabaya 2007 IBBS 2011 IBBS 2013 SS

  3.1.6.9. Trends of HIV Prevalence among DFSW by Locations, 2007-2013

  The trends analysis revealed that HIV prevalence declined significantly among DFSW veillance And 2013 Rapid Behavioral Sur in the following locations between 2007 and 2013: Deli Serdang; from 6.1% to 1.6% [p=0.00662, OR 0.254], Jakarta, from 10.2% to 3.8% [p=0.00654, OR=0.337] and in Semarang, from 6.6% to 2.5% [p=0.0229, OR=0.36. Between the same period, HIV prevalence increased in Surabaya from 6.5% to 12.5% [p=0.02754, OR=2.089] and in Denpasar from 14.1% to 20.3% [p=0.04, OR=1.56]. HIV prevalence remained stable in Technical Report: 2013 Sero-Sentinel Sur the remaining locations between 2007 and 2013 (Figure 9).

  • 10% 0% 10% 20% 30% 40% 50% 2007 IBBS 2011 IBBS 2013 SS

  Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey

  The trends analysis of the syphilis prevalence revealed a decline among DFSW between 2007 and 2013 in Deli Serdang from 12.9% to 4.8% [p=0.0037, OR=0.342], in Batam from 16.8% to 3.8% [p<0.00001, OR=0.198] and in Jakarta from 9.2% to 2.5% [p=0.00084, OR=0.253]. The prevalence of syphilis also declined on Jayapura from 6% to 2.4% [p=0.027, OR=2.6(1.08-6.23)]. On the opposite, between the same period, the prevalence of syphilis increased in Batang from 0.9% to 1.2% [p=0.00713, OR=1.488] and in Ambon from 5.2% to 10.2% [p=0.048, OR=0.47(0.22-1)]. The other locations saw their syphilis remaining stable between the study’s periods (Figure 10).

  Figure 10: Trends of Syphilis Prevalence among DFSW by Locations, 2007-2013 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% H IV Prev al el n ce % 2007 IBBS 2011 IBBS 2013 SS

  Figure 9: Trends of HIV Prevalence among DFSW by Locations, 2007-2013

3.1.6.10. Trends of Syphilis Prevalence among DFSW by Locations, 2007-2013

3.1.6.11. Relationship between HIV Prevalence and Syphilis prevalence among

  

Different Key Populations, Sero-Surveillance Survey 2013

  The data showed a strong relation between HIV and syphilisprevalence among all the key populations (R-Squared=0.9656). The prevalence of HIV and syphilis were not correlated among PWID as their main mode of transmission of HIV is unsafe drug injections and not sexual intercourse.

  Figure 11: Correlation between HIV and Syphilis Prevalence among DFSW, MSM, and Transgenders, 18% 16% SSS 2013 19.0%, 16.2% ence 12% 14% y = 0.8698x - 0.0159 R² = 0.9659 17.3%, 12.7% Sy al v p il h is P re 10% 6% 8% 10.0%, 5.7% 0% 2% 4% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 2.1%, 1.1% vey

  HIV Prevalence veillance And 2013 Rapid Behavioral Sur Technical Report: 2013 Sero-Sentinel Sur

3.2. Results of the 2013 HIV Rapid Behavioral survey

  3.2.1. Participation rate Table 14: Sample sizes by locations for the Rapid Behavioral Survey, 2013 Sero-Surveillance Survey Jakarta Bandung Semarang Malang Surabaya Denpasar Medan Total Banyuwangi MSM 240 240 240

  720 DFSW 240 240 240 400 1120 7 PWID 240 240 44 240

  225 989 Total 480 480 284 240 480 240 400 2829 225

  Data for the rapid behavioral survey from integrated location were collected from the cities and locations as follow:

  ƒ

  PWID: Medan City, DKI Jakarta, Bandung City, Semarang City, Surabaya City

  ƒ

  DFSW: Semarang City, Denpasar City, Malang City, Banyuwangi district

  ƒ MSM: DKI Jakarta, Bandung City, Surabaya City.

  The planned sample size for each key population was 240 per selected site except from DFSW in Denpasar were the planned sample was elevated to 400 because of its size of DFSW. The participation rate was maximal for in all the cities and location except from Semarang where the sample size for PWID was reached at 18% and in Medan where PWID were reached at 94%. vey

3.2.2. Risk behaviors among key population

3.2.2.1. Direct female sex workers

  From the 2013 Rapid Behavioral Survey, the weekly median number of clients per DFSW in Semarang was four clients. The highest number of clients per DFSW per week was noted in Denpasar (14 clients) followed by Malang (eight clients) and Banyuwangi (seven clients). veillance And 2013 Rapid Behavioral Sur

  The proportion of DFSW who used condom during their last commercial sexual intercourse was 76.5% in Denpasar, 71.3% in Malang and Banyuwangi and 68.8% in Semarang. Consistent condom use during the last week preceding the survey was reported at 65.5% in Denpasar, 38.3% in Semarang, 35.1% in Banyuwangi and 24.2% 7 in Malang. Technical Report: 2013 Sero-Sentinel Sur

  Semarang recruited only 18% of the 240 planned participants

  

Table 15: Prevalence of Risk Behaviors among DFSW in Semarang and Banyuwangi, 2011-2013

Semarang DFSW IBBS 2011 RBS 2013 IBBS 2011 RBS 2013 Banyuwangi

  P, OR (CI 95%) P, OR (CI 95%) Number of Clients

(n=249) (n=240) (n=251) (n=240)

P=0.47, P=0.19, 6(4.5-7.5) 4(2.8-5.2) 7 (3.8-10.2) per week (Median) OR=1.47(0.65-3.35) 4 (1.6-6.4) OR=0.54(0.2-1.2) Proportion of DFSW

  P=0.14, who used condom

  P=0.99, during the last 75.2(72.5-77.9) 68.8(65.9-71.7) OR=1.37(0.9-2) 71.1 (65.5-76.7) 71.3 (65.6-77) commercial sex OR=0.98(0.7-1.5)

  Proportion of DSFW

P=0.0037,

who used condoms in commercial sex 52(48.9-55.1) 38.3(35.2-41.4) OR=1.73(1.2-2.5) 35.1(29.2-41) 12.5 (10.4-14.6) P=0.0000, OR=3.78(2.4-6) the last week Table 16: Prevalence of Risk Behaviors among DFSW in Malang and Denpasar, 2011-2013

DFSW P, OR (CI 95%) P, OR (CI 95%)

IBBS 2011 RBS 2013 Malang Denpasar IBBS 2011 RBS 2013

Number of Clients P=0.22, P=0.94,

(n=249) (n=240) (n=248) (n=400)

  5(2.3-7.7) 8(6.3-9.7) 14(9.7-18.3) 14(10.6-17.4)

per week (Median) OR=0.59(0.3-1.2) OR=1(0.6-1.6)

Proportion of DFSW

  P=0.00003, who used condom vey commercial sex during the last OR=1.99(1.3-3.1) 83.2(78.6-87.8) 71.3(68.4-74.2) P=0.0025, 90(86.3-93.7) 76.5(72.3-80.7) OR=2.74(1.71- 4.4)

  Proportion of DSFW P=0.00009, who used condoms in commercial sex OR=2.57(1.74-3.78) 49.6(43.4-55.8) 65.5(63.2-67.8) 44.9(38.7-51.1) 24.2(21.5-26.9) P=0.000002, OR=0.52(0.38- 0.72) the last week veillance And 2013 Rapid Behavioral Sur

3.2.2.2. Men who have sex with men

  The results of the 2013 Rapid Behavioral Survey showed that 73% of MSM in Jakarta used condoms during their last sexual intercourse, compared to 43% in Bandung and 53% in Surabaya. In none of the three cities surveyed, MSM reported the use of Technical Report: 2013 Sero-Sentinel Sur injectable drugs.

  Table 17: Prevalence of Risk Behaviors among MSM inJakarta, Bandung and Surabaya, 2011-2013 Jakarta Bandung Surabaya RBS RBS N 250 240 250 240 248 240 MSM (%) IBBS 2011 2013 95%) 2013 95%) 95%) P, OR (CI P, OR (CI P, OR (CI IBBS 2011 IBBS 2011 RBS 2013 Ever Injected 0(0-0) 0(0-0) 0.00097 0.8(0.2- Using a 5.2(3.8-6.6) 0(0-0) 1.4) 0.46 1.2(0.5-1.9)

  1.25 condom at last 43(39.9- P=0.2, P=0.2, P=0, commercial 67.7(64.8- 73(70.2- OR=0.8 49(45.9- OR=1.3 75.9(73.2- 53(49.8- OR=2.8 (1.9-4.1) sex 1.1) 70.6) 75.8) (0.5- 52.1) 46.1) (0.9-1.8) 78.6) 56.2)

  3.2.2.3. People who inject drugs The study results indicated that the proportion of PWID who have tested for HIV was highest in Medan (66.2%); followed by Jakarta (64%), Surabaya (47.5%), Bandung (41%), and Semarang (25%). The proportion of PWIDs sharing needles was lowest in Surabaya (0.8%) followed by Medan (3.1%). The remaining locations, Jakarta, Bandung, and Semarang had rates of PWIDs who shared needles at their last injection above 10% (Tables 18-21). Table 18: Prevalence of risk Behavior among PWID in Medan, 2010-2013

  IDUs (%) Medan RBS 2010 vey

  IBBS 2011 (n=250) RSC 2013 P, OR (CI 95%) Never Tested for HIV 63.6(57.5-69.7) 66.2(60.2-72.2) [P=0.62, OR=0.89(0.61-1.3)] (n=210) (n=225) Proportion of IDUs sharing month needle during injection last 4.8(2.1-7.5) 3.1(0.9-5.3) [P=0.48, OR=1.57(0.61-4.1)] veillance And 2013 Rapid Behavioral Sur Proportion of IDUs not sharing

  60(56.7-63.3) 97.8(95.9-99.6) P<0.00001, OR=0.034(0.014- needle during the last injection 0.086)

  Technical Report: 2013 Sero-Sentinel Sur

  Table 19: Prevalence of Risk Behavior among PWID in Jakarta, 2010-2013

  IDUs (%) Jakarta RBS RSC 2013 P, OR (CI 95%) Never Tested for HIV 2010(n=210) IBBS 2011 (n=250) (n=240) 71.6(65.9-77.3) 64.2(58.1-70.2)

  Proportion of IDUs sharing needle during injection last 20.1(15-25.2) 17.1(12.3-21.8) [P=0.095, OR=1.41(0.96- month

  2.06)] Proportion of IDUs not sharing

  93.8(90.7-96.8) [P=0.48, OR=1.2(0.77-1.92)] needle during the last injection Table 20: Prevalence of risk Behavior among PWID in Bandung, 2010-2013

  IDUs (%) Bandung RBS

  IBBS 2011 (n=250) RSC 2013 (n=240) P, OR (CI 95%) Never Tested for HIV 2010(n=210) 59.6(53.4-65.8) 41.3(35-47.5) [P=0.00007, OR=2.1(1.47-3.01)] sharing needle during 18(13.1-22.9) 10.8(6.9-14.8) [P=0.033, OR=1.81(1.07-3.04)] Proportion of IDUs injection last month vey the last injection sharing needle during 84.8(82.3-87.2) 98.8(97.3-100.2) P<0.00001, OR=0.07(0.02-0.23) Proportion of IDUs not Table 21: Prevalence of risk Behavior among PWID in Semarang, 2010-2013

  IDUs (%) Semarang RSC RSC 2013 P, OR (CI 95%) veillance And 2013 Rapid Behavioral Sur Never Tested for HIV 27.1(21.5-32.7) 25(19.5-30.5) [P=0.9, OR=1.12(0.52-2.4)] 2010(n=210) IBBS 2011 (n=169) (n=44)

  Proportion of IDUs sharing month needle during injection last 18.9(13.9-23.9) 11.4(7.3-15.4) [P=0.34, OR=1.82(0.67-4.99)] Proportion of IDUs not sharing 95.7(94.3- Technical Report: 2013 Sero-Sentinel Sur needle during the last injection 97.1) 86.4(82-90.7) P=0.04, OR=3.53(1.19-10.48)

  Table 22: Prevalence of risk Behavior among PWID in Surabaya, 2010-2013

  IDUs (%) Surabaya RBS IBBS 2011 RSC 2013 P, OR (CI 95%) Never Tested for HIV 2010(n=210) (n=250) (n=240) 77.6(72.3-82.9) 47.5(44.3-50.7) [P=0.0000, OR=3.83(2.59-5.66)]

  Proportion of IDUs sharing needle during injection 8.4(4.9-11.9) 0.8(-0.3-2) [P=0.0002, OR=10.9(2.5-47.07)] last month sharing needle during the 56.2(52.8-59.5) 99.2(98-100) P<0.0001, OR=0.01(0.003-0.045) Proportion of IDUs not last injection

3.2.3. Comparison between risk behaviors between the 2011 Integrated Biological and Behavioral Survey and 2013 Rapid Behavioral Survey

  There has not been a significant declined of the median number of DFSWs' sexual clients per week in the four cities surveyed. However, the results showed a significant declined of the proportion of DFSW who used condom during their last sexual encounter in Malang and in Denpasar. This rate dropped from 83.2% to 71.3% [P=0.0025, OR= 1.99 (1.29-3.07)] in Malang. In addition, in Denpasar, that drop was from 90% to 76.5% [P=0.00003, OR=2.74(1.71-4.4). It is also worth noting that the proportion of DFSW who reported consistent condom use during the last week prior to the survey declined significantly from 35.1% to 12.5% [P<0.001, OR=3.78(2.38-5.99)] in Bandung and from 44.9% to 24.2% [P<0.001, OR=2.57 (1.74-3.780] in Malang. It was noted that the use condom in commercial sex among DFSW during the same period increased significantly from 49.6% to 65.5% in Denpasar [P<001, OR=0.52 (0.38-0.72)]. vey The percentage of MSM injecting drugs dropped from 5% to 0% in Jakarta between 2011 and 2013 (p<001) but remained stable in the other cities. The proportion of MSM who used condom during their last sexual encounter dropped significantly in Surabaya from 75.9% to 53% [P=00001, OR=2.79(1.9-4.1)].

  The comparison of data from the 2011 Integrated Biological and Behavioral Survey and the 2013 Rapid Behavioral Survey revealed that there have been a significant drop in the proportion veillance And 2013 Rapid Behavioral Sur of PWIDs who ever tested for HIV from 59.6% to 41.3% in Bandung [P<0.001, OR=2.1(1.5-3)].

  This was also noted in Denpasar from 77.6% to 47.5% [P<0.001, OR=3.83(2.59-5.66)] from 2011 Integrated Biological and Behavioral Survey to the 2013 Rapid Behavioral Survey. During the same period of time, proportion of PWIDs who shared needles during the last injection dropped significantly from 18 % to 10.8 % [P=0.033, OR=1.81(1.07-3.04)] in Bandung and from 8.4 % to 0.8 % [P=0.0002, OR=10.9(2.5-47.07)] in Surabaya. Technical Report: 2013 Sero-Sentinel Sur

Chapter IV: Conclusion, Discussion and Recommendations

4.1. Conclusion

  The 2013 Sero-Surveillance Survey was conducted in 16 locations (districts/cities) and included five key population groups namely people who inject drugs, direct female sex workers, men who have sex with men and transgenders.

  HIV and syphilis prevalence

  • Generally, HIV prevalence remained very high among key populations in the surveyed locations and especially among PWIDs who had the highest prevalence of 44.5% followed by transgenders 19%, MSM 17.3% and DFSW 10%.
  • Syphilis prevalence is very high among transgenders (16.2%); MSM (12.7%), moderate among DFSW (5.7%) and low among PWID (1.6%).
  • When compared to the 2011 Integrated Biological and Behavioral Survey results in the same locations, the 2013 Sero-Surveillance Survey results showed that HIV prevalence remained stable in all key populations surveyed except from MSM where the overall HIV prevalence significantly increased from 10.6% to 17.3%.
  • Within the MSM subpopulation, Bandung and Surabaya had their HIV prevalence significantly increased during this period and syphilis prevalence remained stable, but at high levels, in all the locations surveyed
  • In comparison to the 2011 Integrated Biological and Behavioral Survey results, the vey

  2013 Sero-Surveillance Survey showed that the overall HIV prevalence among PWID subgroup was stable but, at location level, it significantly increased in Malang while it also significantly decreased in Bandung. The survey also showed that syphilis prevalence remained very low among this subpopulation, except in Medan and Jakarta where rates of 7.3% and 3.8% where observed.

  • In comparison to the 2011 Integrated Biological and Behavioral Survey data, this survey showed that the overall HIV prevalence remained stable and the syphilis veillance And 2013 Rapid Behavioral Sur

  prevalence among DFSW declined in the locations surveyed. However, HIV prevalence among significantly declined among DFSW in Jakarta and Batang from 10.5% to 3.8% and in Batang from 20.7% to 9.4% respectively. Similarly, syphilis prevalence significantly declined in six locations by 40 to 90% (Batam, Batang, Surabaya, Jayapura, Deli Serdang, Bandung) but significantly increased in Ambon by more than 90%.

  • Overall, transgenders were characterized by high and stable HIV prevalence and a Technical Report: 2013 Sero-Sentinel Sur

  declining prevalence of syphilis in 2013 although HIV and syphilis prevalence among transgenders decrease significantly between 2007 and 2013

  • HIV prevalence dropped from 23.8% to 19% [p=0.01, OR=1.33 (1.07-1.65)] and syphilis prevalence decreased from 27.5% to 16.2% among transgenders [p<0.000001, OR=1.96 (1.57-2.44)] from 2007 to 2013
  • Bandung, Malang, and Surabaya noted significant declined of syphilis prevalence among transgenders. Syphilis prevalence declined from 25.2% to 14% in Bandung [p=0.00204, OR=.0483] and from 28.8% to 17.1% in Surabaya [p=0.00198, OR=.509] and from 20.8% to 4.2% [p<0.00001, OR=0.165] in Malang between 2007 and 2013
  • Malang had a significant decrease of both HIV prevalence and syphilis prevalence between 2011 and 2013

  Behaviors

  • Condom use at last sexual encounter among MSM rates are comparable to that of 2011 in the IBBS. It fluctuated from 67% to 73% in Jakarta and 49% to 43% in Bandung. However, it significantly declined from 75% to 53% in Surabaya.
  • Compared to 2011 Integrated Biological and Behavioral Survey results, HIV testing rates among PWIDs were relatively low and comparable in Medan, Jakarta, and Semarang. The HIV testing significantly decline from 59% to 41% in Bandung and from 78 to 47.5% in Surabaya.
  • Compared to the 2011 IBBS, the rate of sharing needles during drug injection during the past last month remained relatively high among PWIDs in all the locations surveyed except from Medan (from 4.8% to 3.1%) and Surabaya (from 8% to 0.8%) which have maintained rates below 10%.
  • Compared to the 2010 Rapid Behavioral Survey conducted in the same locations except Jakarta, the proportion of PWIDs who reported not sharing needles during vey their last drug injection increased from 60% to 97% in Medan, in Surabaya from 56% to 99%, and from 85% to 98% in Bandung. It dropped from 95% to 86% in Semarang.
  • The median number of clients of DFSW remained comparable to that of 2011

  (IBBS) in Semarang, Banyuwangi, Malang and Denpasar. While the proportion of DFSW who use condom during their last commercial sexual encounter remained comparable to that of 2011 Integrated Biological and Behavioral Survey in Semarang and Banyuwangi (from 75% to 68% and from 71% to 71% respectively), this rate veillance And 2013 Rapid Behavioral Sur declined from 83% to 71% in Malang and from 90% to 76.5% in Denpasar.

  • The proportion of DFSW who reported consistent condom use during commercial sex the past week declined in 2013 Sero surveillance survey from 52% to 38.3% in Semarang and from 44.9% to 24% in Malang compared to the rate in the 2011 IBBS. However, this rate significantly increases in Denpasar from 49% to 65% during the same period.
  • Technical Report: 2013 Sero-Sentinel Sur

4.2. Discussion

  The 2013 Sero-Surveillance Survey indicated that the pattern of HIV infection in the surveyed locations is identical to that found in the region [7]. The survey indicated that there is an increase of HIV prevalence among MSM in the surveyed locations. Although the overall HIV prevalence in these locations and their individual HIV prevalence is relatively lower than that reported in the region[8], caution should be made in interpreting this data because the prevalence of syphilis remained stably high in these locations between the 2011 and 2013. Surabaya noted a concomitant increase of HIV prevalence and a decrease in the proportion of MSM who use condom during their last sexual encounter. An association already documented in the past and which suggests an increase of syphilis with inconsistent condom use. In Bandung also, there has been a slight decline in the use of condom among MSM though that decline was not statistically significant[9]. Jakarta has a rate of condom use at the last sexual encounter of 73%. This may have slowed the progression of the epidemic in the subpopulation. To maintain HIV prevalence at the current level or to lower it, Jakarta should seek to increase the use of condom among MSM above the current coverage. The transmission of HIV among PWID is principally through needle sharing. The prevalence of among PWIDs in the surveyed location was higher than that reported in the region. This should be a great concern especially that this rate remained constant from 2011 to 2013[10] and the proportion of people injecting drugs is increasing[9]. HIV prevalence decreased in Bandung during the period between 2011 and 2013. Among PWID, the district has seen a reduction of the proportion of sharing needles during the last month prior to the surveys by 44% between the two surveys. There was an increase of the proportion of PWID who didn’t sharing needles during the last injection from 85% to 98% among PWID. This is a vey very positive outcome of the needle exchange program as documented in other studies elsewhere [11].

  On the other hand, Surabaya has noted an increase in the proportion of PWID not sharing needles during the last injection and the proportion of sharing needles during the last month before the survey but the HIV prevalence among PWID remained stable. The study showed that the proportion of PWID who have tested for HIV is around 50%. veillance And 2013 Rapid Behavioral Sur This is among the highest documented in Central Asia [12]. HIV testing is considered as the gateway to HIV prevention and care. Knowledge of own HIV status enable individuals allows one to access treatment and therefore reduce their risk of transmission of HIV to their partners. However, the author stigmatized the effect of stigma and discrimination on accessing HIV counseling and testing. Both should be fought addressed to increase the proportion of key population knowing their HIV status [13].

  There is different scenario which could explain the current observation. This could be due Technical Report: 2013 Sero-Sentinel Sur to the younger age of the new recruits in the subgroup or may be due to the fact that many of the PWIDs who have tested HIV could have been on ART, therefore reducing the what is currently happening among the PWIDs in the surveyed locations. The overall HIV prevalence remained stable while syphilis prevalence decreased among DFSW between 2011 and 2013. This is an encouraging finding as the relation between STIs and HIV is well documented [14].From the behavioral data available, the prevalence in Denpasar remained stable but high and the syphilis prevalence is still stably high too. In this district, the high median number of clients of DFSW per week is very high (14), there has been a decrease of the prevalence of condom use at last commercial sex and a relatively low proportion of sex workers reporting using condom during commercial sex during the previous week. This association of risk behaviors is very dangerous as it can spike HIV transmission among clients to FSW and therefore increase the transmission among the general population [15]. This situation, if sustained, will predispose Denpasar to an increase of HIV prevalence and other STIs among direct female sex workers. Malang had a stable HIV and syphilis prevalence between 2011 and 2013. In this district, the median number of clients per direct female sex worker remains high (5), there have been a decline in the proportion of DFSW using condom during their last commercial sex (from 83% to 71%) and condom use during commercial sex in the week prior to the surveys declined even further (from 44.9% to 24%). Again, this is worrisome for the future of the epidemic among DFSW and indirectly among the general population in this location. Semarang had a high number of clients per DFSW per week as the other districts. Transgenders were characterized by a high and stable HIV prevalence and a declining prevalence of syphilis in most of the locations. Of all the districts surveyed, only Malang had both HIV and syphilis declined between 2011 and 2013. In Bandung, syphilis declined and the hope is that in the future, the prevalence of HIV will also decline vey

4.3. Recommendations

  ƒ

  Efforts should be scaled up to increase and/or revamp HIV prevention program with a priority for all districts/cities to:

  • Increase condom use among all KAPs, especially MSM, Transgenders and DFSW
  • STIs screening and treatment for MSM, Transgenders and DFSW and reduction of clients per DFSW though behavioral change communication
  • Increase rates of HIV testing among key affected populations to allow access to veillance And 2013 Rapid Behavioral Sur care and support for those infected and to adopt protective behaviors to prevent the transmission of HIV to their partners

  ƒ

  Efforts to understand the characteristics and behaviors of different KAP subpopulations is needed to comprehend the epidemic

  ƒ

  With the introduction of the Strategic Use for ART, investments should be made to measure incidence in different key affected populations. Technical Report: 2013 Sero-Sentinel Sur

  ƒ

  Ensure that future Sero-Surveillance Survey and Rapid Behavioral Surveys are well- coordinated so that future data analysis covers associations between risk behaviors and biological outcome usefully inform the epidemiology of HIV in Indonesia

  ƒ

  Strategic selection of indicators and adequate sample sizes are critical for monitoring the epidemic over time

  vey veillance And 2013 Rapid Behavioral Sur Technical Report: 2013 Sero-Sentinel Sur

  Reference 1. Indonesia, M.o.H., Intergrated Biological and Behavioural Survey 2007. 2007.

  2. Indonesia, M.o.H., Intergrated Biological and Behavioural Survey 2011. 2011.

  3. World Health Organization. Epidemic Disease Control., UNAIDS., and UNAIDS/ WHO Working Group on Global HIV/AIDS and STI Surveillance., Second generation surveillance for HIV : the next decade. 2000, Geneva: World Health Organization. 40 p.

  4. Paz-Bailey, G., et al., A case-control study of syphilis among men who have sex with men in New York City: association With HIV infection. Sex Transm Dis, 2004. 31(10): p. 581-7.

  5. Indonesia, N.A.C., Rapid Behavioral Survey among FSW 2010-translated. Unpublished, 2010. Unpublished(Unpublished).

  6. National AIDS Commission, I., Rapid Behavioral Survey among IDU 2010-translated.

  Unpublished, 2010. Unpublished(Unpublished): p. Unpublished.

  7. Needle, R., et al., PEPFAR's evolving HIV prevention approaches for key populations-

  • people who inject drugs, men who have sex with men, and sex workers: progress, challenges, and opportunities. J Acquir Immune Defic Syndr, 2012. 60 Suppl 3: p. S145-51.

  8. Lim, S.H. and R. Chan, HIV infection among men who have sex with men in East and South-East Asia - time for action. Sex Health, 2011. 8(1): p. 5-8.

  9. Koss, C.A., E.F. Dunne, and L. Warner, A systematic review of epidemiologic studies assessing condom use and risk of syphilis. Sex Transm Dis, 2009. 36(7): p. 401-5.

  10. UNAIDS., UNAIDS 2013 Global Report. 2013. vey 11. Needle exchanges do not boost drug use, study says. IDU remains major HIV risk factor.

  AIDS Alert, 2003. 18(9): p. 112, 114.

  12. Terlikbayeva, A., et al., Access to HIV counseling and testing among people who inject drugs in Central Asia: strategies for improving access and linkages to treatment and care. Drug Alcohol Depend, 2013. 132 Suppl 1: p. S61-4.

  13. Panda, S. and M. Sharma, Needle syringe acquisition and HIV prevention among veillance And 2013 Rapid Behavioral Sur injecting drug users: a treatise on the "good" and "not so good" public health practices in South Asia. Subst Use Misuse, 2006. 41(6-7): p. 953-77.

  14. Creek, T.L., et al., Declining syphilis prevalence among pregnant women in northern Botswana: an encouraging sign for the HIV epidemic? Sex Transm Infect, 2005.

  81(6): p. 453-5.

  15. Williams, J.R., et al., Positive Impact of Increases in Condom Use among Female Sex Workers and Clients in a Medium HIV Prevalence Epidemic: Modelling Results from Technical Report: 2013 Sero-Sentinel Sur Project SIDA1/2/3 in Cotonou, Benin. PLoS One, 2014. 9(7): p. e102643.

  Technical Report: 2013 Sero-Sentinel Surveillance And 2013 Rapid Behavioral Survey 48 2011, 2013 2013 2011, 2012, 2013 Province District/City DFSW IFSW HRM Waria MSM IDU Prisoner Youth DFSW IFSW HRM Waria MSM IDU Prisoner Youth DFSW IFSW HRM Waria MSM IDU Prisoner Youth DFSW Waria MSM IDU FSW MSM IDU Kota Medan B H H BSS T s Deli Serdang B H T Kepulauan Riau Kota Batam B B H H BSS T Bandar Lampung, B B H T Lampung Selatan Jakarta Barat B B Jakarta Timur

  Jakarta Utara B S B B H T T T S S Jakarta Selatan/South Jakarta Pusat H 5 districts S B B BSS B B H BSS T Bandung B B B B H B B B B H T T T T S S Bekasi S S H H Karawang S Semarang B B B B S B B H B H H H BSS T S Batang S B B H T Surabaya B B B B B B BSS B B H B B H BSS T T T T S S Malang S S S S S B B B H H H T T T T S S Banyuwangi B S B T S Bali Denpasar B S B B H H BSS T S Nusa Tenggara Kupang S H H H T Sulawesi Selatan Makassar S Papua Barat Sorong H H H Maluku Ambon B B H T Jayapura B B B B B H BSS T Jayawijaya T Merauke S S S Wamena B Sumatera Kota Palembang B B s B Banten (Banten) Tangerang & Sekitarnya B B s B H BSS Di Yogyakarta Kota Yogyakarta B B s B H BSS Kalimantan Timur ( Samarinda & Sekitarnya B B H Kalimantan Kota Pontianak & Sekitarnya B B B B H BSS Sulawesi Selatan (S Kota Makassar B B B B H BSS Sulawesi Utara Kota Bitung & Sekitarnya B B H Irian Jaya Barat (W Kota Sorong B B s Papua (Papua) Kota Timika B B H S Behavioral survey B Behavioral + HIV and Syphilis test + Other biological testing H Behavioral + HIV and Syphilis test

  BSS Behavioral Suvey only T HIV testing and Syphilis GR O U P TW O Papua G ROU P ON E Sumatera Utara Lampung DKI Jakarta Jawa Tengah Jawa Timur RBS SSS Jawa Barat 2007 2009 2011 IBBS 2013

  Appendix A. IBBS and RSS Location and Target Group

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