SEXUAL BEHAVIOR AMONG WARIA IN 3 INDONESIAN CITIES Jakarta Surabaya Bandung Pandu Riono, Ph.D, Public Health Department, University of Indonesia Ignatius Praptoraharjo, Health Policy and Administration, University of Illinois at Chicago and The Fogarty AIDS International Training and Research Program at the University of Illinois at Chicago

Waria “Waria” is a non-derogatory term for male to female transgender Derived from 2 Indonesian words: wanita (female) and pria (male). Refers to an identity, behavior, and performance that is associated with being female by someone who was born male. Does not discriminate as to whether or not the person has had surgical reassignment, exclusively wears women’s clothes, and/or uses female hormonal drugs.

The AIDS Epidemic in Indonesia, including among Waria Aggregate national HIV prevalence is as low as 0.16% but rapidly rising* 193,000 Indonesians are estimated to be living with HIV Most HIV infections are believed to occur through use of contaminated injecting equipment, unprotected paid sex and, to a lesser extent, unprotected sex between men. Estimated number of waria is 28,000; clients of waria sex workers number about 80,000 HIV prevalence among waria in some cities is from 3.5% to 30%** National AIDS Commission, (2007), Country report on the Follow up to the Declaration of Commitment On HIV/AIDS (UNGASS),Reporting Period 2006-2007, Jakarta **Compiled from District/City Health Office Reports on HIV Serosurvey for selected most at risk groups and Report of National BSS 2004-2005, Ministry of Health 2006.

Risk factors associated with the high HIV prevalence among male to female transgender (waria) Behavioral Factors: Drug Use High-risk sexual practices Female hormonal and silicon injection Psychosocial Factors Sexual identity conflict Isolation and Fear Search of affirmation Contextual Factors: Prostitution Low education and Skills Poverty Poor access to existing health care services Discrimination Jeffrey H. Herbst, Elizabeth D. Jacobs, Teresa J. Finlayson, Vel S. McKleroy, Mary Spink Neumann, Nicole Crepaz, Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review, AIDS Behav (2008) 12:1–17 Don Operario,Toho Soma, Kristen Underhill, Sex Work and HIV Status Among Transgender Women Systematic Review and Meta-Analysis, (J Acquir Immune Defic Syndr 2008;48:97–103)

Problem Little is known about the association between behavioral, psychosocial & contextual factors and HIV prevalence and risk behaviors among waria in Indonesia. This study examines risk for HIV through unprotected anal sex among waria in 3 Indonesian cities : Jakarta Bandung Surabaya

Methods A two-stage cluster sampling design was used to select location samples (cluster) and respondents in the 3 Indonesian cities. 750 waria were recruited and interviewed by using a standard National BSS questionnaire for waria. Outcome variables: unprotected anal sex based on two types of male sex partners  unpaid and commercial partners. Predictor variables: demographic characteristics, behavioral factors, and contextual factors. Logistic regression was used to estimate the associations.

Key Findings: Respondent Characteristics (N=750) On average, the waria informants: Were about 32 years old; Had less than a high school education Had engaged in sex work for about 12 years 15% used illegal drugs, but almost two-thirds consumed alcohol 42% reported having undergone silicon injection in the previous year.

Continued 80 percent had high HIV knowledge as measured by a 10-item knowledge index 72% also saw themselves at high risk for HIV 54% reported being stigmatized and discriminated against due to their gender identity.

Sexual Contact with Unpaid and Commercial sexual partners 56% of the waria reported having had sex on average with 2 unpaid (regular and casual) sex partners in the previous year 94% of the waria engaged in sex work Average number of commercial sex partners was 4 per week, Average price per sexual act was $2.30 (USD) 56% reported having had sexual experiences in cities besides their own. 54% reported unprotected anal sex with their sexual partners.

Factors Associated with Unprotected Anal Sex The likelihood of reporting unprotected anal sex with unpaid sex partners was greatest among waria: who were younger (OR:0.47; p<0.01). had experienced discrimination as a waria (OR: 2.53; p<0.001). had multiple unpaid sex partners (OR: 2.50; p<0.001) had less commercial sex partners (OR 0.40; p<0.001). had unprotected anal sex with commercial sex partners (OR:12.20; p<0.001). The likelihood of reporting unprotected anal sex with commercial sex partners was greatest among waria: from Bandung when compared to Jakarta (OR: 2.33; p<0.001) among those who reported engaging in unprotected anal sex with their unpaid sex partners (OR: 11.27; p<0.001)

Continued The likelihood of having experienced discrimination as a waria and engaging in unprotected anal sex was: Two and half times more likely to occur with unpaid sex partners (OR: 2.53; p<0.001) Almost two times less likely to occur with commercial sex partners (OR: 0.55; p<0.001) Better educated waria and those with a higher self-perceived risk for HIV were more likely to engage in safer anal sex (OR: 0.66; p<0.003 and OR: 0.57; p<0.001 respectively)

Discussion Dynamic of sexual partnership between waria and their unpaid sex partners contributes to the likelihood of unprotected commercial anal sex. Psychological factors such as self-affirmation and conflict identity may be contributors for having unprotected anal sex. Different type of sexual partner may associate with different self-perceived risk for HIV.

Continued Most of waria depend on sex work for survival given their low education, older age, and experiences with social discrimination. Potential for the sexual transmission of HIV from sero-positive waria to their sexual partners is high. Waria are not isolated from other sexual networks.

Conclusions Waria in all 3 cities appear to be at high risk for HIV through unprotected anal sex with both unpaid and commercial sex partners Knowledge about HIV prevention and the availability of condoms alone clearly are not enough to prevent unprotected anal sex.

Recommendations HIV prevention programs for waria must also target the type of sexual partner. Interventions are urgently needed to address the social factors, including stigma and economic disadvantage, that contribute to warias’ high risk for acquiring HIV. The waria community needs to be engaged in planning for prevention, care and support needs.

Acknowledgement The National AIDS Commission (NAC),Indonesia Ministry of Health of Government of Indonesia The Central Bureau of Statistic Program Aksi Stop AIDS - Family Health International (FHI) Indonesia HIV Prevention and Care Project (IHPCP) Judith A. Levy, Ph.D, Director of the Fogarty AIDS International Training and Research Program at UIC. Further information: Ignatius Praptoraharjo iprapt2@uic.edu