Baseline prevalence and risk factors associated for STIs among newly-arrived female sex workers in Timika, Indonesia

Presented by

Nurlan SilitongaASHM Conference, Cairns, 23 October 2003

Silitonga N, Donegan E, Davies SC, Kaldor J, Wignall FS,

Okoseray M, Schachter J

Acknowledgements

• Mimika District Health Office• PT Freeport Indonesia• International SOS• University of California, San Francisco• Naval Medical Research Unit No 2• Sexually Transmitted Infectious

Research Centre – University of Sydney

• University of New South Wales• Ford Foundation

IndonesiaIndonesia

• 39 active mining companies (30,000 miners). • The mines are mostly in remote locations,

employ male workers• An increasing number of FSWs has become

available for these men • Most of the women are poor and illiterate.

Little information on STIs and often have little negotiating power for condom use

HIV/AIDS and STIs in Indonesia• The HIV/AIDS program

primarily in urban areas and focuses on HIV testing

• Diagnosis and treatment of STIs are rarely available

• Many people do self-treated

• Inadequate STI health care services

• HIV/AIDS program tends to rely on donor agencies

Timika• A mining town in Papua

province where a large gold mining company is operating with 12,000 male employees

• Approximately 600 FSWs

• In 1997, a survey among 462 mining employees – Visited brothel complex (14%) and local bars (20%)

– Low level of condom use (3%)

– Not aware of their risk of contracting STI/HIV infection (48%)

• 1995 - First HIV cases

• 1997 – A partnership between District Health Office and PTFI in developing HIV Prevention program was established:

– Behavior change

– Provision of STI care

Aim of studyAim of study• Prevalence and risk factors associated with STIs

among the FSWs attending the STI clinic for the first time from January 1997 – June 2002

MethodsMethods• We recruited FSWs from the only brothel, local

bars and from the street

MethodsMethods• Every month each bar/brothel receives a reminder

of the availability of clinic appointments

• Clinic participation is voluntary

• A clinic administrator – acts as an ombudsman solving problems– organizing clinic visits – maintaining a log of the number of FSWs living in each

bar or house at the brothel

VariablesVariables• Sociodemographics

– Type of sex worker (Brothel, Bar, Independence / freelance / street)

– Age and place of origin

• Sexual behavior – Contraceptive use

– Having regular partner and their occupation

– Frequency of sex in the past one week

– Condom use

• Consistent (100% condom use during their sexual acts in the past one week)

• Inconsistent (less than 100% or no condom)

Specimens & testsSpecimens & tests

• Posterior fornix vaginalis tested for Trichomonas vaginalis (TV) by wet mount

• Endocervical samples tested for Nesseria gonorrhoeae

(NG) by culture and LCR

• Urine samples tested for Chlamydia trachomatis (CT) by LCR

• Blood samples tested for – RPR and TPHA– HIV tests (Immunoblot, ELISA) confirmed by WB

Statistical MethodsStatistical Methods

• Data of FSWs who attended the STI clinic for the first time were selected, almost all of whom are newly arrived in Timika

• Data were analysed by EPIINFO 6.4 and SPSS version 11.5

• To test for trends over time of categorical variables, a logistic regression model was used.

• To adjust for multiple risk factors, multivariate analysis was performed: variables associated with STIs on univariate analysis were included in a backward selection logistic regression model

ResultsResults

• Socio-demographic characteristics– Most of the 3086 FSWs recruited

worked in the brothel (63%) or bars (34%) and most originated from Java (70%) or Sulawesi (25%)

– Age mean (median) =25 (26)

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

Characteristics Brothel Bar and freelance

95% CI P

Age in years (mean) 27.6 23.4 4.2 (3.82-4.64) 0.0001

Java as place of origin (%) 91.8 18.1 40.4 (30.66-53.29) 0.0002

Use contraceptive use (%) 53.3 25.5 3.3 (2.84-3.91) 0.000

Frequency of sex in the last week (mean)

5.4 2.8 2.6 (2.09-3.04) 0.000

Consistent condom use (%) 14.0 9.7 1.5 (1.09-2.12) 0.014

Regular partner (%) 10.2 29.1 0.3 (0.23-0.34) 0.0001 T-test2 Chi-square testCI, confidence interval

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

Year

1997 1998 1999 2000 2001 2002 P

Number of sex workers 702 584 500 466 495 339

Age >25 (%) 47.7 46.4 52.2 54.5 50.9 53.4 0.014

Place of origin (%)

Java 93.2 69.8 84.2 65.3 59.4 61.4 0.000

Outside Java 6.8 30.2 15.8 34.7 40.6 38.6 0.000

Sex venues (%)

Brothel 61.1 52.2 77.6 64.8 59.8 61.4 0.253

Freelance 1.4 2.4 5.6 5.2 3.4 7.7 0.000

Bar 37.5 45.4 16.8 30.0 36.8 31.0 0.002

Having regular partner (%) 14.2 21.4 20.8 15.9 14.9 16.5 0.597

Consistent condom use (%) NA 8.1 11.6 12.1 15.1 16.3 0.001

Chi-square test for linear trend for categorical variables. NA, not available, as the data on sexual behaviour was not collected in 1997 and 1998. Reported condom use during a week prior their visit to the clinic.

Fig. 1. Annual prevalence rates of CT, NG, TV, syphilis, and HIV among female sex workers attending STI Clinic in Timika 1997-2002.

0

5

10

15

20

25

30

35

40

45

1997 1998 1999 2000 2001 2002

% w

ith

se

xu

all

y tr

an

sm

itte

d i

nfe

cti

on

s

Gonorrhoea Trichomonas Syphilis HIV Chlamydia

P=0.005

P=0676

P=0.003

P=0.546

P=0.003

Table 3. Risk factors associated with any STIs

Risk factors n infected / n tested (%) Odds ration (95% CI)

Unadjusted P Adjusted P

Type of sex venues

Bar and freelance 432/1158 37.3 1.0

Brothel 615/1928 31.9 0.8 (0.68-0.92) 0.002 NS

Age (years)

≤ 21 ® 260/660 39.4 1.0

21-25 322/872 36.9 0.9 (0.73-1.11) 0.325 1.0 (0.80-1.35) 0.778

26-30 263/858 30.7 0.7 (0.55-0.84) 0.000 0.8 (0.63-1.08) 0.164

31+ 202/696 29.0 0.6 (0.50-0.79) 0.000 0.7 (0.51-0.89) 0.006

Place of Origin

Other region 203/579 35.1 1.0

Jawa 425/1366 31.1 0.8 (0.68-1.03) 0.089

Contraception

No 648/1764 36.7 1.0

Yes 399/1322 30.2 0.7 (0.64-0.87) 0.000 0.8 (0.63-0.93) 0.006

Frequency of sex

No sex 153/542 28.2 1.0

1-4 324/1084 29.9 1.1 (0.86-1.36) 0.488 1.1 (0.87-1.38) 0.433

5-9 115/370 31.1 1.2 (0.86-1.53) 0.353 1.2 (0.88-1.58) 0.259

> 9 76/206 36.9 1.5 (1.06-2.09) 0.022 1.6 (1.11-2.21 0.011

Condom

Consistent 57/210 27.1 1.0

Inconsistent/nil 458/1450 31.6 1.2 (0.90-1.71) 0.194

Having a regular partner

No regular partner 848/2553 33.2 1.0

Mining worker 66/179 36.9 1.2 (0.86-1.61) 0.317

Other 98/257 38.1 1.2 (0.95-1.62) 0.112

Table 4. Factors associated with inconsistent condom use

Risk factors n inconsistent / n sex (%) Odds ratio (95% CI)

Unadjusted P Adjusted P

Type of sex venues

Bar and freelance 483/535 90.3 1.5 (1.09-2.12) 0.014 NS

Brothel 967/1125 86.0 1.0

Age (years)

≤ 21 308/332 92.8 2.8 (1.69-4.49) 0.000 1.7 (1.00-3.15) 0.069

21-25 416/458 90.8 2.1 (1.41-3.20) 0.000 1.7 (1.02-2.37) 0.042

26-30 395/468 84.4 1.2 (0.81-1.66) 0.414 1.0 (0.69-1.57) 0.859

31+ 331/402 82.3 1.0

Place of Origin

Other region 362/397 91.2 2.0 (1.34-2.95) 0.000 1.6 (1.02-2.50) 0.042

Jawa 686/818 83.9 1.0

Contraception

No 818/923 88.6 1.3 (0.97-1.73) 0.081

Yes 632/737 85.8 1.0

Frequency of sex

1-4 914/1084 84.3 1.0

5-9 339/370 91.6 2.0 (1.36-3.04) 0.001 2.0 (1.30-3.14) 0.002

> 9 197/206 95.6 4.1 (2.05-8.10) 0.000 5.1 (2.30-11.80) 0.000

Having a regular partner

No regular partner 1116/1307 85.4 0.3 (0.17-0.62) 0.000 0.4 (0.19-0.96) 0.039

Mining worker 108/192 94.7 1.0 (0.35-2.80) 0.989 1.4 (0.40-5.00) 0.599

Other 182/192 94.8 1.0

Discussion• First study of its kind in Indonesia

• Suggests a partnership with business corporation in developing HIV/AIDS intervention program is feasible

• Young age, high frequency of sex, having regular partner and place of origin can be predictors in choosing an intervention for behavioural change

Discussion• This study revealed an increase in consistent

condom use over time. However, the rate is still very low, which may have little impact on reducing the transmission of STIs.

• Increase in the prevalence of HIV infection is worrying, as the prevalence of other STIs such as CT, NG and syphilis in this group study remains high

Discussion (Limitations)• There was low representation of women from the street /

freelance / independence (3,9%)

• There were incidents of closing brothel/bars in year 1998 and 1999 which may dramatically reduce the number of sexual encounters

• The frequency of screening was reduced from every month to every two months in 2001, and so newly-arrived FSWs who came to the clinic in 2001 and thereafter were exposed to more partners

• Accuracy for NG testing - In 1997 and 1998, the NG culture was performed with manual CO2 incubator

Conclusions• High prevalence of STIs, low consistent condom

use and increasing HIV prevalence among these FSWs require enhanced interventions

• FSWs in Indonesia are vulnerable to HIV transmission, and a partnership with industry can help in developing an intervention program

• Further study on freelance or street FSWs is required

Thank you