Travel agent and tour guide perceptions on travel health promotion in Bali.

The increasing number of travelers to Bali has been accompanied by the increased risks of travel-related health problems. Travel agents and tour guides are in a key position to inform travelers about these matters; nonetheless, little evidence was found on their role in the promotion of travel health. This article aims to assess travel agent and tour guide perceptions on their possible involvement in promoting travel health measures in Bali. A cross-sectional study was conducted between July and October 2015, involving 500 respondents (250 travel agents and 250 tour guides), who were chosen systematically from the Bali-based members of the Association of the Indonesian Tours and Travel Agencies. Data were collected using questionnaires, and perception indicators were developed using concepts from social learning theory and health belief model. Both groups have good levels of knowledge of general travel health issues, with mean percentages (SD) of 67.1 (11.9) and 66.2 (10.0) for travel agents and tour guides, respectively. Tour guides were more likely than travel agents to deliver information on health risks [PR (95%CI) = 1.31 (1.10-1.56); p = 0.003]; and on safety hazards during travel [PR (95%CI) = 1.22 (1.01-1.46), p = 0.04]. Overall, the majority of respondents (>68%) have positive and very positive perceptions of possible involvement in travel health and safety programs, although tour guides have statistically better perceptions (z = -2.2, p = 0.03). Based on perception levels, previous experiences and levels of knowledge, travel agents and tour guides have great potential to be involved in travel health promotion programs in Bali.

Understanding the Social Influences on Engaging Key Populations With HIV Prevention: A Qualitative Study With Men Who Have Sex With Men in Three Indonesian Cities.

The globally recognized test and treat approach underpins Indonesian national strategies to reduce and prevent HIV among key populations, including men who have sex with men. More comprehensive understanding of how engagement with HIV prevention is shaped by social and community practices will support these efforts. Between 2015 and 2016, focus groups and semi-structured interviews were conducted with 54 men who have sex with men in three urban settings in Indonesia to elicit their views on, and experiences of, HIV prevention and care. Focused on data relating to testing, findings documented the important influence of informal peer networks, community-based organizations and outreach workers. Some social dimensions of service access complicated this, particularly fear of stigma or lack of confidentiality in large service settings. The many differences between men challenges assumptions that a single set of HIV prevention strategies will work to engage all men who have sex with men living in Indonesia.

Four-year safety follow-up of the tetravalent dengue vaccine efficacy randomized controlled trials in Asia and Latin America.

OBJECTIVE: Our objective was to describe the risk of hospital admission for virologically confirmed dengue (VCD) and the risk of clinically severe hospitalized VCD occurring up to 4 years after the first dose (years 1 to 4) in three randomized clinical trials comparing tetravalent dengue vaccine with placebo. METHODS: The relative risks (RR) for hospitalized VCD from first dose to year 4 were estimated by year and age-group in individual and combined studies. RESULTS: Overall, from Year 1 to Year 4, 233 and 228 participants had at least one episode of hospitalized VCD in the vaccinated (n = 22 603) and placebo (n = 11 301) groups, respectively (RR = 0.511, 95% CI 0.42-0.62). Among these, 48 and 47 cases, respectively, were classified as clinically severe. In children aged ≥9 years, 88 and 136 participants had at least one episode of hospitalized VCD in the vaccinated (n = 17 629) and placebo (n = 8821) groups, respectively (RR = 0.324; 95% CI 0.24-0.43). In vaccinated participants aged <9 years, particularly in those aged 2-5 years, there were more hospitalized VCD cases compared with the control participants in Year 3 but not in Year 4. The overall RR in those aged <9 years for Year 1 to Year 4 was 0.786 (95% CI 0.60-1.03), with a higher protective effect in the 6-8 year olds than in the 2-5 year olds. CONCLUSIONS: The overall benefit-risk remained positive in those aged ≥9 years up to year 4, although the protective effect was lower in years 3 and 4 than in years 1 and 2.

Sharply rising prevalence of HIV infection in Bali: a critical assessment of the surveillance data.

This study critically examines serological survey data for HIV infection in selected populations in Bali, Indonesia. Sero-survey data reported by the Bali Health Office between 2000 and 2010 were collated, and provincial health staff were interviewed to gain a detailed understanding of survey methods. Analysis of time series restricted to districts that have used the same sampling methods and sites each year indicates that there has been a steady decline in HIV prevalence among prisoners, from 18.7% in 2000 to 4.3% in 2010. In contrast, HIV prevalence among women engaged in sex work increased sharply: from 0.62% in 2000 to 20.2% in 2010 (brothel based), and from 0% in 2000 to 7.2% in 2010 (non-brothel based). The highest prevalence was recorded among people who injected drugs. Recent surveys of gay men and transvestites also found high prevalences, at 18.7% and 40.9%, respectively. Review of the methodology used in the surveys identified inconsistencies in the sampling technique, sample numbers and sites over time, and incomplete recording of individual information about survey participants. Attention to methodological aspects and incorporation of additional information on behavioural factors will ensure that the surveillance system is in the best position to support prevention activities.

HIV testing experience of drug users in Bali, Indonesia.

Recently, large increases have been noted in injection drug use and HIV prevalence among drug users in Indonesia. The objective of this study was to examine the experience of drug users with HIV testing in Bali, Indonesia. In-depth interviews were conducted with a sample of 40 drug users who had injected heroin in the Denpasar, Bali area. The users' experience with testing highlighted the importance of pre- and post-test counselling that provides clear information, confidentiality and assistance in developing social support.

The Bali STD/AIDS study: association between vaginal hygiene practices and STDs among sex workers.

OBJECTIVES: To assess the association between genital cleansing practices and the prevalence of sexually transmitted diseases and of sexual health knowledge among female sex workers in Bali, Indonesia. METHODS: Low priced commercial sex workers (CSWs) participated in the Bali STD/AIDS Study, a 3 year educational project evaluating the effect of education on the subsequent use of condoms and the prevalence of STDs and AIDS. Structured interviews, genital evaluation, laboratory evaluation for STDs, and treatment were performed. Vaginal cleansing characteristics including frequency, type, and reasons for use, were evaluated. Associations between these characteristics and the presence of bacterial and viral genital infections were assessed. RESULTS: Of 625 female sex workers evaluated between May and July 1998, 99.1% used substances, such as soap and toothpaste, to clean the vagina at least daily, with 69.3% performing this after each intercourse. The women using such cleansers after each client did not differ from those using them once or less daily in education, AIDS and condom use knowledge, time working as a CSW, or number of clients in the previous day. However, they were younger than those using vaginal cleansers daily or less, and reported lower condom usage in the past week. Several genital symptoms, such as discoloured discharge and odour, were reported less by women with the highest frequency of vaginal cleanser use. Prevalence of genital infections in this population of women was substantial, with bacterial infections more prevalent than viral infections. Infections were not associated with the type of cleanser used, using a genital cleanser on the day of examination, or using a cleanser after each client versus daily or less, except for candida colonisation, which was more prevalent in women cleansing after each client (OR=1.87, 95% CI 1.21, 2.90). However, symptomatic candida vulvovaginitis (positive culture plus presence of symptoms) was not associated with the prevalence of genital cleansing. Women using genital cleansing in part for "infection avoidance" (39.7%) were more likely to have heard of STDs and AIDS, but were less knowledgeable about these infections, compared with women not citing this reason for genital cleansing. CONCLUSION: Commercial sex workers in low priced brothels in Bali have a high rate of genital infections, with lower rates of viral compared with bacterial infections. Genital cleansers, on a daily or after each intercourse schedule, are used routinely. Although genital cleansing after each intercourse was associated with fewer genital symptoms, the prevalence of STDs did not differ significantly based on this frequency, and the women's knowledge of STDs and AIDS was less than that of women cleansing less often. The effect of genital cleansing in general on STD and AIDS prevalence could not be assessed in this population owing to the lack of a non-cleansing cohort. Further study to elucidate the effect of vaginal cleansing practices on STD prevalence and resistance is needed.

Evaluation of a peer education programme for female sex workers in Bali, Indonesia.

The objective of this paper is to evaluate a peer education programme for female sex workers in Bali, Indonesia. Sex workers participated in face-to-face interviews and STD exams in August-September 1998. In October 1998 one woman from each of 30 clusters was selected to be a peer educator and received a 2-day training on AIDS, STDs, condom use, and condom negotiation. After training, the peer educators were visited twice a week by field workers to answer questions and offer support. All sex workers received group education every 2 months. In January-February 1999, the sex workers again participated in face-to-face interviews and examinations. One month after peer education training, only 50% of the peer educators were still working in the clusters where they were trained. To evaluate the impact of the peer educators, sex workers in clusters where a peer educator continued to work were compared with sex workers in clusters where women did not continue to work (n=189). In clusters where women continued to work, there were higher levels of AIDS knowledge (P < 0.05), STD knowledge (P < 0.05) and condom use (82 vs 73%, P=0.15). The prevalence of Neisseria gonorrhoeae infection was also lower in clusters with a peer educator (39% vs 55%, P=0.05) than in clusters without a peer educator.

AIDS and STD knowledge, condom use and HIV/STD infection among female sex workers in Bali, Indonesia.

The objectives of this paper were to examine changes in AIDS/STD knowledge and behaviour from 1992-1998, current levels of STD infection and psychosocial and demographic determinants of condom use and STD infection among female sex workers. Data for the study were drawn from cross-sectional surveys of female sex workers conducted in 1992, 1994 and 1997-8. For each survey, women participated in a face-to-face interview in the brothel complexes. Survey questions included information on AIDS/STD knowledge, demographics, sexual history and psychosocial factors related to condom use. After the last survey, women were offered a vaginal exam for STD diagnosis and treatment. Sera were tested for HIV infection (anonymous, Elisa/Western blot) and syphilis (TYPHA, RPR). Cervical mucous was tested for chlamydia (LcX), gonorrhea (LCx), herpes (pcr) and HPV (pcr). Knowledge of AIDS and awareness of STDs has increased tremendously in this population since 1992. Reported condom use has also increased substantially (69.9%). Perceived susceptibility toward HIV infection remains low. Ineffective preventive strategies such as medication use continue to be common. HIV infection remains very low in this population (0.2%), although the prevalence of other STDs such as gonorrhea (60.5%), chlamydia (41.3%) and HPV (37.7%) were very high. STD knowledge and self-efficacy were significantly related to condom use as were the sex workers' perceived susceptibility to STD and HIV infection. Women with a larger number of partners were more likely to be infected with gonorrhea, chlamydia and HIV. Women who had come to Bali recently were more likely to be infected with HIV and gonorrhea.

Factors related to condom use among four groups of female sex workers in Bali, Indonesia.

This article tests a behavioral model of condom use for four groups of female commercial sex workers. Data were drawn from a study of 614 female sex workers conducted in Bali, Indonesia. AIDS knowledge, risk behaviors, and factors related to condom use varied substantially among the four groups of women and reflect the social context of their work. Interventions for each group need to reflect these differences. Important factors to consider include the level of AIDS and STD knowledge in their environment, the characteristics of the clients served, and the degree of supervision that they receive.

PIP: The efficacy of a behavioral model of condom use was evaluated in 4 groups of commercial sex workers in Bali, Indonesia, in 1992-93: 1) women working in low-price complexes supervised by a pimp in the Denpasar area (n = 407); 2) mid-price women who rent rooms within family complexes or bungalows (n = 77); 3) women working at high-price houses in and around Denpasar (n = 50); and 4) independent workers at the Kuta tourist resort (n = 80). Mean knowledge scores among the 614 prostitutes ranged from 8.3 to 11.6 out of a possible 19. Common misconceptions were that an HIV-infected person could appear healthy and that AIDS can be cured with medicine or injections. The mean number of clients in the week preceding the interview was 15.8 at low-price brothels, 10.5 in the bungalow group, 4.7 at high-price houses, and 3.2 at the resort. Condom use with clients was 19%, 68%, 71%, and 90%, respectively. The effects of independent variables on condom use were evaluated through multiple regression analysis. Among women in the low-price and bungalow groups, condom use was significantly associated with beliefs about condoms' ability to prevent sexually transmitted disease (STD) and pregnancy, the belief condoms enhance sexual pleasure, perceived susceptibility to STDs (but not HIV), self-efficacy, number of clients in the past week, and pregnancy history. For women in the resort area, condom use was related to beliefs about the ability of condoms to protect against STDs and AIDS, perceived susceptibility to HIV infection, and experience with an STD. Finally, among high-price prostitutes, condom use was associated with the belief condoms prevent AIDS and increase pleasure, self-efficacy, and pregnancy experience. These findings indicate that levels of AIDS knowledge and the extent of risky behaviors are related to the particular social context in which sex work is practiced.

Correlates of condom use among female prostitutes and tourist clients in Bali, Indonesia.

This study examines the commercial sex activity of both tourist client and local prostitute groups in the host country of Indonesia. The study provides a profile of social and behavioural characteristics of foreign tourist men and Indonesian women engaging in commercial sex, using cross-sectional data gathered in the tourist resort town of Kuta, Bali. Univariate statistical analysis and multiple logistic regression are used to assess psychosocial and other factors associated with consistent condom use in commercial sex encounters, drawing from the Health Belief model and social cognitive theory. Results from both respondent groups indicate that condom use is high between tourist clients and female Indonesian sex workers, although not 100% consistent. Beliefs about condom efficacy and effects on pleasure, as well as susceptibility to STD infection were related to condom use for female sex workers. Beliefs about condoms being too much trouble, and self-efficacy were related to condom use for tourist clients.

PIP: This study examines the commercial sexual activity of both male tourist clients and local female prostitutes in the host country of Indonesia. The study provides a profile of social and behavioral characteristics of male tourists and Indonesian women engaging in commercial sex using cross-sectional data gathered in the tourist resort town of Kuta, Bali. Univariate statistical analysis and multiple logistic regression are used to assess psychosocial and other factors associated with consistent condom use in commercial sex encounters, drawing from the Health Belief model and social cognitive theory. Results from both respondent groups indicate that condom use is high between tourist clients and female Indonesian sex workers, although not 100% consistent. Beliefs about condom efficacy and effects on pleasure, as well as susceptibility to STD infection, were related to condom use for female sex workers. Beliefs about condoms being too much trouble and self-efficacy were related to condom use for male tourist clients.

Behavioral interventions for reduction of sexually transmitted disease/HIV transmission among female commercial sex workers and clients in Bali, Indonesia.

OBJECTIVE: To describe and evaluate a behavioral intervention targeted to low-price female commercial sex workers (CSW) in large brothel complexes, their pimps, and their male clients. DESIGN AND METHODS: Fieldwork was conducted during 1994 in Bali, Indonesia. Intervention activities included an education program for CSW, pimp training, condom sales and distribution, and client media. Theoretical perspectives guiding the intervention were the Health Belief Model and social cognitive theory. Baseline and evaluation surveys were conducted to evaluate the intervention. RESULTS: Both AIDS and sexually transmitted disease (STD) knowledge increased significantly over the intervention period. Condom use for vaginal sex with paid partners the day before the interview increased substantially in the two intervention areas: 18-75% and 29-62%. Condom use also increased in the control area, although the difference between baseline and evaluation measures was smaller. Multivariate analyses indicated that programmatic factors such as attendance at education sessions and reading the project brochure were related to condom use. CONCLUSIONS: Increasing community knowledge and awareness among low-price CSW, pimps, and clients regarding AIDS and STD using trained outreach workers is feasible and effective. In summary, this study has documented the effectiveness of a behavioral intervention for CSW and their clients.

AIDS knowledge, risk behaviors, and condom use among four groups of female sex workers in Bali, Indonesia.

The objectives of this study were to discover the AIDS knowledge, risk behaviors, and condom use of four groups of female professional sex workers (n = 614). Personal interviews were conducted with women working in low-price brothels, mid-price and high-price houses, and tourist areas. Only 51% of women in the low-price brothels had heard of AIDs, although most of the women in the other groups had heard of it. Knowledge of transmission and symptoms was weak in all groups, and most women were unaware of asymptomatic transmission. Most women felt safe from HIV due to ineffective strategies such as taking medications or client selection practices. Condom use with clients varied widely by group. Women in the low-price brothels reported the lowest levels of use (19% of encounters in the previous week), with women from the mid- and high-price groups reporting higher levels (68% mid-price; 71% high-price). Women working in the tourist areas reported the highest levels of use (90%). Interventions for each group need to reflect these differences in knowledge as well as the contexts of their work; important contextual factors to consider include the level of AIDS and STD knowledge in their environment, the characteristics of the clients served, and the degree of supervision that they receive.

AIDS knowledge and risk behaviors among domestic clients of female sex workers in Bali, Indonesia.

This study investigated AIDS and STD knowledge, risk behaviors and condom use among clients of female commercial sex workers in Bali, Indonesia. Although these clients were varied in their socioeconomic status, they all tended to have low levels of knowledge concerning HIV and STD transmission and prevention, multiple sexual partners, low frequencies of condom use with these partners, and experienced frequent STDs. Although HIV sero-prevalence rates are currently low in Indonesia, clients of CSWs are at high risk of HIV transmission. Given their high mobility and frequent sexual encounters with CSWs in other parts of Indonesia, these men could well be agents of rapid spread of the virus throughout Indonesia. Interventions to prevent the spread of the HIV virus must be targeted not only to CSWs, but also to their clients. These interventions should include educational activities concerning AIDS and STD transmission and prevention, condom promotion, efforts to improve condom availability, and activities to strengthen the health sectors' STD diagnosis and treatment capabilities for both CSWs and their clients.

AIDS knowledge, risk behaviors, and factors related to condom use among male commercial sex workers and male tourist clients in Bali, Indonesia.

OBJECTIVES: To describe the AIDS/sexually transmitted diseases (STD) knowledge and risk behaviors, and to determine factors related to condom use among male commercial sex workers (CSW) and male tourist clients in Bali, Indonesia. DESIGN: Individual survey interviews were conducted with a sample of 80 male CSW and 100 tourist clients in the Kuta area of Bali. METHODS: Survey interviews included detailed questions on AIDS/STD knowledge, sexual behavior, and psychosocial measures related to risk taking. RESULTS: Most of the male CSW had heard about AIDS and other STD, although some misconceptions about transmission and risks of different sexual practices remained. Both oral and anal intercourse with tourists were common and condom use was far from consistent. Factors related to condom use for anal intercourse with tourist clients were condom beliefs, self efficacy, susceptibility to STD infection, and STD knowledge. Tourist clients were mainly from Australia and Europe and many had paid for sex in other parts of Indonesia as well as in high prevalence countries. Knowledge of AIDS/STD was very good among the tourists and previous experience with STD was common. Factors related to condom use with male CSW were condom beliefs and self efficacy. CONCLUSION: There is a very active and mobile group of male CSW and tourist clients present in Bali. Interventions with these men are needed due to the low level of knowledge about AIDS among CSW, their experience with STD and STD symptoms, and their level of risky sexual behavior.

PIP: Interviews conducted in 1992-93 with 80 male commercial sex workers in Bali, Indonesia, and 100 of their tourist clients revealed low levels of accurate knowledge about acquired immunodeficiency syndrome (AIDS) and widespread high-risk sexual behaviors. Although most male sex workers were aware of AIDS, 30% did not know that healthy-appearing persons could be infected. The mean number of clients in the week preceding the interview was 2.8 (range, 0-12); 61% had engaged in anal intercourse in that period. Condom use with clients averaged 48% for receptive anal intercourse, 55% for insertive anal intercourse, and 14-17% for oral intercourse; these rates were 19%, 33%, and 0%, respectively, for unpaid partners. Only 30% of clients serviced by male prostitutes insisted on condom use. Factors related to condom use with commercial clients were condom beliefs, self-efficacy, perceived susceptibility to infection, and knowledge of sexually transmitted diseases. The tourist clients, 60% of whom were from Europe and 25% from Australia, were significantly older (mean age, 38.4 years) than the sex workers. 64% reported a history of STD infection, primarily gonorrhea. In the week before the interview, clients had an average of 1.7 paid and 0.3 unpaid partners and 53% engaged in anal intercourse. Condom use was 75% for receptive and 69% for insertive anal intercourse. Although 87% of tourists brought condoms to Bali, only 62% knew of a local source. Factors related to condom use with a commercial sex worker were condom beliefs and self-efficacy.

Contraceptive pricing and prevalence: family planning self-sufficiency in Indonesia.

Imposing or increasing user fees can move family planning programs toward self-sufficiency. But, economic theory predicts that quantities demanded decrease following price increases; and, that the size of the response depends, all else constant, upon the share of income accounted for by spending on the good or service. This article uses survey data collected in conjunction with an Indonesian self-sufficiency program to assess the differential magnitudes of contraceptive usage responses to price differentials between sample-wide and relatively poor households, and for both subsidized and full private-sector prices. We find a much more substantial response among poor households. As prices move up toward full cost-recovery, the effect is magnified.

The Bali Indirect Maternal Mortality Study.

The Bali Indirect Maternal Mortality Study (BIMMS) was conducted in Bali Province, Indonesia in 1991. The objective of the study was to evaluate the indirect sisterhood method for estimating maternal mortality, using a prospective (direct) community-based survey undertaken from 1980 to 1982 among women of reproductive age (Reproductive Age Mortality Survey, or RAMOS) as a comparison. The BIMMS maternal mortality ratio was 331 per 100,000 live births adjusted for 1982. This ratio is similar to the RAMOS one prior to its adjustment, of 359 per 100,000 live births. The sisterhood method was faster, cheaper, and appears to be as accurate as direct methods.

PIP: The sisterhood method (Graham et al.) was used to estimate maternal mortality in Bali, Indonesia as a practical, less expensive method with quicker results. Data were based on a prospective community-based survey of reproductive age females in Bali between 1980 and 1982, which was conducted by the National Family Planning Coordinating Board of Indonesia. The sample was a multistage probability proportional sample including 10,005 households and 30,711 persons interviewed. The risk of dying from maternal causes was calculated with adjustments for sisters who had not reached reproductive age and time-location; methods were based on those described by Graham et al. The average number of persons per household was 3.1. There were 9545 aged 15-19 years and 8112 aged 20-24 years, which were adjusted upwards to 10,266 and 8215, respectively. The lifetime risk of maternal death was estimated only with data from the 45-49 year age group. The risk was computed as 1 in 102. The maternal mortality ratio was based on data from respondents aged 15-34 years. The maternal mortality ratio for 1982 was estimated at 331 deaths/100,000 live births, when total fertility is assumed to be 2.9. The maternal mortality rate was computed as 32.8 deaths/100,000 women of reproductive age, based on the 1982 general fertility rate of 99 live births/1000 women aged 15-49 years and a maternal mortality ratio of 331 deaths per 100,000 live births. The maternal mortality ratio increased from 282 in 1978 to 331 in 1982. The increase was attributed to differential use of family planning by healthier women, and decreased live births were higher than decreased deaths. Significant underreporting suggested a more accurate maternal mortality ratio of 718 deaths/100,000 live births. The Age Mortality Survey figure was estimated at 359 compared to the sisterhood estimation of 331; the differences were attributed to a variety of causes, but did not change the conclusion that the sisterhood method was appropriate for use in Indonesia.

STD knowledge and behaviours among clients of female sex workers in Bali, Indonesia.

This study investigated knowledge, beliefs, and practices related to STDs and AIDS among clients of low price sex workers in Bali, Indonesia. These men are at high risk of STD and HIV transmission. They have poor knowledge of the basic concepts of STD and HIV transmission and prevention, and they practice a variety of ineffective prevention strategies including partner selection and the prophylactic use of antibiotics. They report a mean of 1.9 paid sexual partners in the previous week and very low frequencies of condom use. Over 25% had experienced an STD symptom in the previous 6 months, with self treatment with antibiotics reported by a third. Recent experience of an STD was related to the number of sex worker partners in the previous month and to ever having used a condom with a sex worker. The implications of the study findings for the development of comprehensive STD control programs including educational campaigns, condom promotion, and the strengthening of STD case management by health care providers are discussed.

PIP: In Indonesia, interviews with 401 16-65 year old clients of low-price sex workers in Bali were conducted to examine knowledge, beliefs, and practices related to sexually transmitted diseases (STDs) and AIDS. They had had a high number of paid sexual partners (mean, 1.9) in the week before the survey. They rarely used condoms (8%). The level of a history of STDs among the clients was high (50%). For example, 34% reported urethral discharge, 20% a genital ulcer, and 25% had a history of syphilis. Almost 20% had had intercourse with a sex worker while experiencing symptoms during their most recent episode. The most common treatment was self-treatment with antibiotics (35-46%). Perceived STD and AIDS prevention strategies were partner selection based on cleanliness or lack of mouth or body odor and prophylactic medications. Most clients (95%) were familiar with STDs. High level of education and previous experience with an STD were positively correlated with STD knowledge (p 0.01 and 0.05, respectively). Most clients (almost 75%) had heard of AIDS, but few had accurate knowledge about HIV transmission. For example, 33% believed that medication would prevent HIV infection. AIDS knowledge level was positively associated with age (p 0.001), education (p 0.001), and never having been married (p 0.05). Five or more sex worker partners in the previous month and never use of a condom with a sex worker were positively associated with having recent STD symptoms (relative risk = 3.34 (for syphilis) and 2.41, respectively; p 0.01). These findings indicate a need for developing a comprehensive STD control program consisting of educational campaigns, condom promotion, and improving case management by health providers. Specific messages for campaigns should revolve around recognition of STD symptoms, possibility of asymptomatic infection, need for medical consultation at onset of STD symptoms, inefficacy of existing STD prevention strategies, and consistent use of condoms.

AIDS and STDs: risk behaviour patterns among female sex workers in Bali, Indonesia.

This study investigated AIDS and STD knowledge, risk behaviour patterns and condom use among three distinct groups of female commercial sex workers (CSWs) in Bali, Indonesia. Individual in-depth interviews were conducted with 71 female CSWs. These CSW groups differ in the prices they charge, their places and modes of employment, educational backgrounds, levels of AIDS and STD knowledge, number of clients served and levels of condom use. Knowledge of the routes of transmission and appropriate prevention practices is low among all groups, and despite significant differences in their number of clients and their condom use, all groups report high levels of STD symptoms. Although HIV seroprevalence rates are currently low in Indonesia, high risk sexual behaviour patterns place all three groups of CSWs and their clients at great risk of infection. Interventions targeted to specific groups of CSWs and clients should be undertaken as soon as possible, including educational activities utilizing peer educators, condom promotion and distribution, together with improved STD diagnosis and treatment for CSWs and their clients.

PIP: The World Health Organization projects that by the year 2000 Asia will have the largest number of people infected with HIV in the world. HIV is spread most frequently through sexual contact, so concern exists over the role of female sex workers and their clients in the spread. This paper attempts to describe knowledge about AIDS and other sexually transmitted diseases (STD), risk behavior patterns, and condom use among 3 distinct groups of female prostitutes in Bali, Indonesia, with the goal of ultimately discussing the implications. The groups differ in the prices they charge, their places and modes of employment, educational backgrounds, levels of AIDS and STD knowledge, the number of clients served, and levels of condom use. On the basis of interviews with 71 of the women, it was determined that women in all groups had low knowledge of transmission routes and appropriate prevention practices. All reported high levels of STD symptoms. Although current levels of HIV seroprevalence in Indonesia are low, the frequent high-risk sex behavior of these prostitutes puts them and their clients at high risk of infection. Interventions should therefore be targeted to specific groups and their clients as soon as possible, and include educational activities which employ peer educators, condom promotion and distribution, along with improved STD diagnosis and treatment for the workers and their clients.