ATTITUDE OF YOUTHS TOWARDS HIV/AIDS AND CONDOM USE

(CASE STUDY UNIVERSITY STUDENTS BANDUNG CITY)

TRIAL PROPOSAL

NAME: MUWAGA MUSA.

NOR: 190220093001.

INSTRUCTOR: IBU TIA

DEAR READERS AM REQUESTING YOU TO SEND ME CRITICISMS IN THIS PROPOSAL AT

musamuwaga@yahoo.com

DEPARTEMEN PENDIDIKAN NASIONAL

UNIVERSITAS PADJADJARAN PROGRAM PASCA SARJAN
FAKULTAS PSIKOLOG PROGRAM MAGISTER PSI
APRIL 06/04/2010

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 Content

Chapter One

Acronyms ………………………………………………………………..…………3
Operational definitions…………………………………………………………….4
Introduction…………………………………………………………………………5
Background…………………………………………………………………………8
Problem Statement…………………………………………………………………10
Rational of the study………………………………………………………………..11
Objectives of the study……………………………………………………………..12
Research questions………………………………....................................................12
Significance of the study …………………………………………………………..13
Hypotheses of the study……………………………………………………………13
CHAPTER TWO
Literature review (theory flame work and theoretical model)
Theory framework and theoretical model……………………………………………14
Condom promotion programs in Asia ……………………………………………….18
Transmission of HIV/AIDs……………………………………………………………24
Prevention of HIV/AIDs………………………………………………………………27
Risky sexual behaviors ………………………………………………………………29
Successful strategies in developing countries ………………………………………..30
Recommendations and education ……………………………………………………..31
Preventive HIV/AIDs testing and counseling …………………………………………32
Intervention for commercial sexual workers…………………………………………..35
Life styles of commercial sex workers ………………………………………………..36

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HIV/AIDs preventive programs in Asia………………………………………………43
CHAPTER THREE
Research methodology………………………………………………………..........50

Location of research …….…………………………………………………………50

Population and sampling……………………………..……………………………50

Research Instruments………………………………………………………………51

Data collection procedure…………………………………………………………51

Secondary data collection …………………………………………………………51

Data analysis procedure……………………………………………………………53

Anticipated problems and solutions ………………………………………………..54

Time flame work for the study……………………………………………………...54

Predicted results and implications …………………………………………………55

References………………………………………………………………….……..56

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Acronyms and Abbreviations

AIDS_ __Acquired-Immune-Deficiency-Syndrome
ART_ __Anti-Retroviral-Therapy
ARV_ __Antiretroviral
CSW_ _ _Commercial-Sex-Worker
DFID_ _ _Department-for-International-Development
FHI_ _ _Family-Health-International
FSW_ _Female-Sex-Worker
GFATM_ _Global-Fund-to-fight-AIDS,-Tuberculosis-and-Malaria
HIV_ _ _Human-Immune-deficiency-Virus
IDU_ _ _Injecting-Drug-User
IMAI_ _ _Integrated-Management-of-Adolescent-and-Adult-Illnesses
M_&_E_ _ _Monitoring-&-Evaluation
MOH_ _ Ministry-of-Health
MSM_ _ _Men-who-have-sex-with-men
NAC_ _ National-AIDS-Commission
NGO_ _ Non-Government-Organization
NSP_ _ _Needle-Syringe-Program
OI_ _ _Opportunistic-Infection
PLHIV_ _ _People-Living-with-HIV
PMTCT_ _ _Prevention-of-Mother-To-Child-Transmission
PSA_ _ _Public-Service-Announcement
STI_ _ _Sexually-Transmitted-Infection
TOT_ _ _Training-of-Trainers
UNAIDS_ __The-Joint-United-Nations-Programme-on-HIV
UNDP_ _ United-Nations-Development-Programme
UNFPA_ _ _United-Nations-Population-Fund
USAID_ _ _United-States-Agency-for-International-Development
VCT_ _ _Voluntary-Counseling-and-Testing

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WHO_ _ _World-Health-Organization
Operational definitions

1. Youths, the United Nations defines youth as persons between the ages of 15 and 24.
UNESCO understands that young people are a heterogeneous group in constant evolution
and that the experience of ‘being young’ varies enormously across regions and within
countries.

2. HIV stands for human immunodeficiency virus, and is the virus that causes AIDS.
HIV destroys certain blood cells that are crucial to the normal function of the immune
system, which defends the body against illness.

3. AIDS stands for Acquired Immunodeficiency Syndrome. It occurs when the immune
system is weakened by HIV to the point where a person develops any number of diseases
or cancers.

4. HIV/AIDs are virus transmitted from person to person through the exchange of body
fluids such as blood, semen, breast milk and vaginal secretions. Sexual contact is the
most common way to spread HIV AIDS, but it can also be transmitted by sharing needles
when injecting drugs, or during childbirth and breastfeeding. As HIV AIDS reproduces, it
damages the body's immune system and the body becomes susceptible to illness and
infection. There is no known cure for HIV infections.

5.Condom a barrier device most commonly used during sexual intercourse to reduce the
likelihood of pregnancy and spreading sexually transmitted diseases (STDs—such as
gonorrhea, syphilis, and HIV). It is put on a man's erect penis and physically blocks
ejaculated semen from entering the body of a sexual partner. Because condoms are
waterproof, elastic, and durable, they are also used in a variety of secondary applications.
These include collection of semen for use in infertility treatment as well as non-sexual
uses such as creating waterproof microphones and protecting rifle barrels from clogging.

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1.0. Introduction

Aids acquired immune deficiency syndrome was recognised in 1981 as a new syndrome
capable of destroying the human beings. The sudden appearance of the epidemic among
previously known rare diseases was recognised on the basis of its association with
immune suppressant characteristics, henceforth, unrecorded in human history.

As a result of the fast HIV/AIDs diagnosed in Pakistan (1987) research study initiated to
determine the status of HIV/AIDs in the province of sindh, Pakistan. Surprisingly, in a
group of 956 (high risk) individuals using ELISA and western blot (WB) techniques
seven (7) HIV-1 and four (4) HIV-2 cases were screened out, whereas 16 individuals
were found out as indeterminate cases.

This study later, was transformed into deliberate research efforts aimed at discovering
treatment of HIV/AIDs pandemic spreading fast in the world.

The alarming incidence of HIV exposure in Asia was a source of motivation to find out
some real effective anti –HIV drug from indigenous traditional medicine /plants
resources. The world health organisation was contacted in this respect and the drug abuse
treatment centre at Karachi as the only recognized government centre in research on drug
abuse treatment in Pakistan.

In 1994, medical research collaborative project was initiated in the ministry of health,
government of Japan and Pakistan entitled “epidemiological studies on viral infections
through blood transfusion in Asian countries” for which Dr Muhammad Rafiq and later
Dr. Asim were selected as members of the project by the Japans government. Nagoya
University, school of medicine under this project, government of Japan offered to extend
the research facilities for HIV/AIDs drug screening.

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Indonesia’s first case of HIV was reported in 1987. There are severe concentrated
epidemics among Indonesia’s injection drug users and sex workers, and growing
epidemics among youths. Due to the increasing number of new infections has grown
rapidly since 1999. Moreover, a generalized epidemic is already under way in the
provinces of Papua and West Papua, where a population-based survey found an adult-
prevalence rate of 2.4% in 2006. A whopping 48% of Papuans are unaware of
HIV/AIDS, and the number of AIDS cases per 100,000 people in the two provinces is
almost 20 times the national average. The percentage of people who reported being
unaware of HIV/AIDS increases to 74% among uneducated populations in the region.
Indonesia established a National AIDS Commission in 1994 to focus on preventing the
spread of HIV, addressing the needs of people living with HIV/AIDS, and coordinating
government, nongovernmental organizations (NGOs), private sector, and community
activities. The Government of Indonesia signified its continued commitment to fighting
HIV/AIDS in 2005 when it budgeted $13 million to HIV/AIDS programs, an increase of
40 percent over the amount disbursed in 2004.

However, the national budget for HIV/AIDS has since been stagnant. A 2006 Presidential
Regulation reinforced the Commission’s position as the National AIDS Strategy for
2003–2007 stressed the role of prevention as the core of Indonesia’s HIV/AIDS program,
while recognizing the urgent need to scale up treatment, care, and support services. The
strategy emphasized the importance of conducting proper HIV/AIDS and sexually
transmitted infection (STI) surveillance; carrying out operational research; creating an
enabling environment through legislation, advocacy, capacity building, and
antidiscrimination efforts; and promoting sustainability. Building upon this framework,
the National AIDS Strategy for 2007–2010 added the priority targets of reaching 80
percent of people most-at-risk with comprehensive prevention programs; influencing 60
percent of the most-at-risk population to change their behaviors; and providing
antiretroviral therapy (ART) to 80 percent of those in need.

The Government initiated a program to subsidize the cost of ART in 2004. By 2005, the
program provided low-cost ART at 50 hospitals. However, only 20 percent of HIV-
infected people received ART in 2006, according to UNAIDS. This is well below the

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country’s target. Treatment adherence continues to be a challenge in the country as more
often than not, people living with HIV drop out of antiretroviral therapy due to many
complex factors. Indonesia's local governments have investigated innovative techniques
to slow down the spread of the disease, including using microchip tagging technology to
keep track of the infected individuals known to be sexually active.

Indonesia receives assistance from several international donor organizations, including

the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund approved a
fourth-round grant in 2005 for Indonesia to provide comprehensive care for HIV/AIDS-
infected and -affected individuals

HIV/AIDS has declined in Indonesia among high risk groups (direct sex workers, indirect
sex workers and motor tax drivers) based on the national center for AIDS / HIV
dermatology and STD 2003 but it appears to have increased among spouse relationships.
From 1997 to 2003, the proportion of men among people living with HIV/AIDS had
increased from 35 to 45% .its hypothesis that, the fact that condoms were not used or
used inconsistently among spouse is the main factor contributing to this high prevalence.

To date, several studies in Indonesia have focused on condom use among high risk
groups and among sweetheart relationships .so far the government and UNSAID are
conducting a campaign to promote condom use in spouse relationships. To assess their
effectiveness, 2 studies were conducted in Jakarta which revealed that the level of
condom use was low among spouses but the reason and reality about the low level of
condom use among spouses were not mentioned in the report.

The main objective of these proposal is to survey the factors influencing the limited
use of condoms among the youths and find out perceptions and reality with regard boys
and girls attitudes towards condom use; find out different expectations and reality with
regard to willingness to take the HIV/AIDS test; find out what kind of social support is
available in order to facilitate them to carry condoms , negotiate /propose condom use
between their spouse ; and make recommendations on how HIV/AIDS agencies can
improve effectiveness and efficiency of their campaign to combat the new transmission
from husband to wives.

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200 youth’s couple selected universities in Bandung will be asked for interview with
survey questioner’s form. Additionally, prior to the field work, in-depth interviews with

1.2. Background

The first case of AIDS was identified in Indonesia in 1987 in a foreign male tourist.
During the decade thereafter, the epidemic appeared to grow slowly, spreading primarily
among men and almost exclusively through sexual transmission. In the mid-1990s,
however, injecting drug use, which historically had been very limited in Indonesia, began
to increase dramatically. Community workers who were aware of the phenomenon
expressed concern about the threat of HIV/AIDs in the growing population of injecting
drug users. Indonesia has an estimated 250,000 sex workers (male, female, and
transgender), and an estimated 8.5 million men buy sex annually in the early years of the
AIDS epidemic, the spread of infection was largely tied to sexual activity—both through
the commercial sex trade and the widespread practice of unprotected sex with both
regular and casual partner.
Although much effort has been invested in promoting consistent condom use in high-risk
sex, progress is slow. The challenge is to influence behavior, not just communicate
information. Studies in several parts of Indonesia and among different segments of the
population (sailors, high school students, IDUs, and truck drivers) have found with
remarkable consistency that even when respondents know about the dangers of
unprotected sex.
However, there were some declines in the spread of epidemic in the country mostly
among high risk groups (direct sex worker, indirect sex and motor Tex drivers. With
regards to prevention awareness’ study conducted by national center for HIV/AIDs
dermatology and STD on HIV surveillance .The report from Ministry of Health (MOH)
in 2002 stated that Indonesia has moved from a low prevalence to a concentrated area
country. This means that there are areas in Indonesia where number of HIV/AIDS cases
has exciding 5% in high-risk behavior groups. Until the beginning of 2004 there were 6
provinces concerned by the high number of HIV/AIDS cases and have become “priority
provinces” (Jakarta, Papua, Bali, East Java, West Java and Riau). At the end of 2004

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Indonesia has 12 priority provinces adding West Kalimantan, North Sumatra, North
Sulawesi, Central Java, Jogjakarta and Banten.

Major mode of transmission is still through sexual activities due to the very low use of
condom in every risky sexual activity, which is less than 10%. However number of
transmission due to sharing needles among IDUs is rapidly accelerating. For example the
HIV/AIDS prevalence of IDUs in Jakarta is more than 50%, the same with Surabaya (the
capital city of East Java), while in Pontianak (the capital city of West Kalimantan) the
prevalence has increased to around 15-25%. The latest joint report by UNAIDS/WHO in
2003 gives an indication that Indonesia now has one of the fastest growing HIV/AIDS
epidemics in the world.

Indonesia has established a National AIDS Commission (NAC) based on Presidential

decree no. 36 / 1994 and at the time being is implementing its HIV/AIDS National
Strategy 2003 – 2007. All provinces and districts have been instructed to have their own
Provincial/District AIDS Commission (PAC/DAC) and also HIV/AIDS
Provincial/District Strategy. However, in reality many of the PAC and DAC are not well
functioned.

On December 2003 the National Narcotics Board and the NAC have signed a
Memorandum of Understanding (MOU). Although the controversy is still high, some
progress due to this MOU has started shown results in several pilot districts with harm
reduction programs for IDUs. On April 2004 Ministry of Manpower also has declared a
commitment to fight HIV/AIDS and urge companies to integrate HIV/AIDS programs as
a way to protect its employees from the transmission. With around 150,000 – 250,000
female sex workers, it is assumed that HIV/AIDS program in the workplace is a strategic
way to provide potential clients of sex workers with information and related services they
needed. In January 2004 the NAC had meeting with 6 governors from 6 priority
provinces and came out with “Sentani Commitment”. It stated that HIV/AIDS is a major
threat to their provinces development programs and a serious action should be taken
immediately including self-funding, acknowledge sex industry to make 100% Condom
Use Program (CUP) success and the need of harm reduction programs for IDUs. After a

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year of the “Sentani Commitment” on 14 February 2005, the NAC met and urged all
related ministries, provinces and other stakeholders to strengthen the commitment and
take more serious responses. Some outcomes are to strengthen social marketing of the
dual protection of condom from BKKBN; statement from the ministry of religion that
condom need to be use if a person consciously aware that out of marriage sex is a sin but
still want to do so; MOH committed to 100% support the purchase of anti retroviral
(ARV) drugs for People Living With AIDS (PLWA) who cannot afford it; MOH will
increase the number of hospitals with complete services for PLWA from 25 hospitals in
2004 to 50 hospitals throughout Indonesia in 2005; and the NAC will have a sub
commission on women, children and young people.

1.3. Problem statement

The purpose of this study is to examine attitudes of youths towards HIV/AIDs and
condom use “to examine the negative tendency of youths towards HIV/AIDs and
condom use in Indonesia,’’ a case study Bandung city, despite efforts from
government and non government organisation to promote condom use among youth as a
method of HIV/AIDs control. The negative tendencies relates to the factors such as less
public awareness, more especially in the area of education, health, gender, and the
application of the participatory methods in the campaign against HIV/AIDs.

The fact that the sex industry is a multimillion-dollar business in Indonesia is not news.
Thousands of people living in the neighborhoods surrounding the brothels and
entertainment sites depend on the commerce generated by these enterprises. Spend any
time in a brothel and one will note the steady stream of entrepreneurs flowing through
with various goods and services: clothing, food, and medicine vendors; carpenters and
other tradesmen making repairs or renovations; and beer and liquor distributors. Staff
includes security guards, cleaning staff, “reception” desk attendants, bartenders, pimps,
parking attendants, and brothel managers. Business partners are rarely seen: RWs, local
police and military personnel, and people referred to as the local “mafia.”

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The key issue here is not that sex work is hidden but that the necessity of sex work as an
economic option is increased where official unemployment is high and social and gender
inequality is widespread.

1.4. Rationale for the study

These days HIV prevalence occurs mainly among youth’s boys and girls. There should be
many factors contributing to high rates, one of these factors in my point of view is related
to neglect to condom use, which are not used consistently among spouses. According to
the study of attitude and behavior related to HIV/AIDS in Bandung which were
conducted in 2002, found out that men use condoms with sex workers who are said to be
suspects, but fail to use them with regular partners especially their wives. Furthermore, an
evaluation of HIV/AIDS media in Bandung by British broadcasting commission (BBC)
word service trust reported that, condom use among married couples is virtually an
existent. Only 6 percent of the married women said they had used a condom the last time
they had sex.

At the same time, many government and non government organisations tend to focus
their studies on condom use among high risk groups. It’s necessary to conduct studies to
increase people’s attitudes and knowledge base and fill existing gaps about HIV/AIDS
and condom use among regular partner especially spouse. Hence , the significance of this
study , will focus on active married men and active married women is to find out how
much knowledge and information they have about aids and whether they have adopted
good practices that enables them to change their behaviors in response to condom use .

And priority responses, we have learned the mechanics of configuring and carrying out
such responses. Implementation should occur on a large scale and reach a majority of
those people at risk of infection, exemplifying the time-honored public health mantra to
“do the right thing, do it right, and do enough of it.” Nowhere are these principles more
important than in Asia, whose size, complexities, and disparities within and between
countries compel an intelligent epidemiological analysis and effective, focused responses.
Despite the diversity of Asia’s HIV epidemic, sufficient commonalities characterize

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broad continental epidemic patterns. AIDS in South Asia What are the central features of
the Asian HIV/AIDs epidemic? In Asia, high-risk behaviors drive much of the epidemic:
injecting drug use and unprotected commercial sex, plus anal sex among subsets of the
population. The sexual partners of those engaged in these behaviors, Also have an
elevated risk of acquiring and transmitting HIV.

1.5. Objectives

The main objectives of this study are;

Identify factors influencing the limited use of condoms among the youths.
Find out perception with regard to boys and girls attitude towards condom use.
Find out about different expectations and reality with regards to willingness to take the
HIV/AIDs test.
Find out what kind of social support is available in order to facilitate them to condoms
propose condom use.
Make recommendations on how HIV/AIDS agencies can improve effectiveness and
efficiency of their campaign to combat the new trend of transmission among the youths.

1.6. Research questions

1. To what extent are condoms used between spouses?

2. Why condom use among spouses is not a common practice? .
3. What are perceptions towards condom use?
4. What form of social support would help married women to negotiate the use of
condoms every time they have sexual intercourse? Who are they? Where do they
come from? And in what context?
5. What qualities of knowledgeable individuals (medical practitioners, relevant
NGOs personnel) could be associated with condoms to make them more
acceptable?
6. What are the deferent expectations and realities with regards to willingness to take
the HIV/AIDS test?

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 7. What are the existing strategies and programs to promote condom use among
spouses in Indonesia? And are these strategies and programs effective and holistic
in the context of Indonesia.

1.7. SIGNIFICANCES OF THE STUDY

The study will act as a data base and as well as a guide for future implementation of the
condom use among spouses.
It will help to identify irregularities arising from the management, hence, forge way
forward for improving efficiency and effectiveness in campaigns to fight against
HIV/AIDS.
The study will help initiate people based attitude and behavior awareness to HIV/AIDS
The study will act as a reference for related future studies by other researchers.
The study will help government to come up with appropriate measures in order to
streamline the implementation of the condom use.

1.8. HYPOTHESES

A hypothesis is a logical supposition (idea), a reasonable guess, an educated conjecture

(guess) which provides a tentative explanation for a phenomenon under investigation.
The hypothesis helps to direct the thinking of the researcher to the possible sources of
information that will aid in resolving one or more sub problems and, in the process, the
principle research problem. The following are the hypothesis based on the above
mentioned research problem.

1. Religious influence among people is strong in Indonesia hence affecting the use of
condom.

2. Failure to take voluntary testing and counseling (VCT) leads to spread of HIV/AIDs.

3. Young boys and girls are exposed to HIV by cultural differences.

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4. Due to incorrect understanding and inadequate knowledge about condom use as a
measure to fight aids

5. Inadequate sensitization of the youths about the dangers of the epidemic makes them
unaware of condom as a measure to control HIV/AIDs.

CHAPTER TWO

2.0 Theory framework and theoretical model (Literature review).

THEORY OF PLANNED BEHAVIOR/ REASONED ACTION BY FISHBEIN AND

AJZEN'

Theory of Reasoned Action suggests that a person's behavior is determined by his/her

intention to perform the behavior and that this intention is, in turn, a function of his/her
attitude toward the behavior and his/her subjective norm. The best predictor of behavior
is intention. Intention is the cognitive representation of a person's readiness to perform a
given behavior, and it is considered to be the immediate antecedent of behavior. This
intention is determined by three things: their attitude toward the specific behavior, their
subjective norms and their perceived behavioral control.

The theory of planned behavior holds that only specific attitudes toward the behavior in
question can be expected to predict that behavior. In addition to measuring attitudes
toward the behavior, we also need to measure people’s subjective norms, their beliefs
about how people care and view the behavior in question. To predict someone’s
intentions, and knowing these beliefs can be as important as knowing the person’s
attitudes. Finally, perceived behavioral control influences intentions. Perceived
behavioral control refers to people's perceptions of their ability to perform a given
behavior. These predictors lead to intention. A general rule, the more favorable the
attitude and the subjective norm, and the greater the perceived control the stronger should
the person’s intention to perform the behavior in question.

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Attitudes include different components. In this study the concept “attitude” is defined
according to Uutela (1985), to include three components. The first is a cognitive
component, such as knowledge that describes what people think. The second component
is affective, such as feelings. The third one is cognitive an action component, the
readiness to behave in a specific way. Individual differences have been detected in the
attitude structure.
There are also other definitions. Huskinson & Haddock (2004) found out that an affect-
based appeal was more persuasive among individuals with affective (as compared to
cognitive) attitudes, and that individuals with cognitive attitudes were more persuaded by

"Theories of Reasoned Action and Planned Behavior as Models of Condom Use: Meta
Analysis." Psychological, Fishbein, and Mucllerleile evaluate the success of the theories
of reasoned action and planned behavior as predictors of condom use across studies and
to examine the plausibility of the relations postulated by these models through meta-
analysis on 96 data sets (published and unpublished articles and theses, dissertations, and
technical reports). Fishbein and Ajzen (1975) theory of reasoned action asserts that one’s
intentions influence overt behavior. The person’s overt action is a function of the
intention or willingness to perform the behavior. For example, “How likely is it that, in
the next six months, you will use a condom the next time you have vaginal sex with her?
One is likely to use condoms if one intends to use them.

The intention is the influence by attitude toward performing behavior and subjective
norm, while attitude is the degree to which one has a positive versus a negative
evaluation of the behavior. The theories of reasoned action have inspired a number of
prevention efforts like CDC’s AIDS Community Demonstration Projects, Project
RESPECT, and preventive software for African Americans. The study suggests that
interventions emphasizing norms and perceived behavioral control alone could be less
effective than programs that attempt to change perceptions of the outcomes of condom
use. The study also finds that changing attitudes will produce greater strides in stemming
the current HIV pandemic.

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While condom use does not reduce the risk of HIV/AIDs transmission to zero, the
substantial protection afforded by condoms is higher than other available prevention
techniques. Male latex condoms have a better method efficacy than any other biomedical
prevention available at the present time. For individuals who want to substantially reduce
their personal risk of contracting HIV/AIDS through heterosexual intercourse, use of
male latex condoms is the most effective choice (after abstinence, of course).

Female Condoms, the Reality is brand female condom is an intravaginal barrier device
marketed as an alternative to the male condom for the prevention of pregnancy and
sexually transmitted infections (HIV/AIDs). It consists of a soft, loose-fitting
polyurethane sheath with two flexible rings. When the device is properly placed, the
inner ring rests behind the pubic bone and over the cervix, while the external ring and
about one inch of the sheath remain outside the vagina and partially cover the external
genitals and the base of the penis during intercourse.

Due to the female condom being a device worn by the woman, it has been hailed by some
as a female-controlled method of contraception and STD prevention that can be used
without the consent of the male partner. This female condom however, is not a device
that can be used repetitiously by the majority of women, and proper use requires the male
to guide his penis into the condom. A follow-up study conducted in Kenya found that the
noncooperation of the man was a factor for women who, despite the opportunity, did not
use the condom.

A similar study in Brazil showed that women recognized their continued use of the
condom was dictated by their male partner. In both studies, however, women indicated
that they felt empowered by the female condom and a large proportion of the women
expressed the desire to continue using it. Thus, while the Reality condom gives more
control to the woman than the male condom, it is not a completely female controlled
technique.
Regardless of the acceptability of the female condom in the society, the key factor for
decision makers is whether or not the condom is an effective barrier to STD and HIV.

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The theoretical efficacy of the Reality condom in preventing HIV There is limited
information available about the method efficacy of the female condom in preventing STD
and no available information about its efficacy in preventing HIV infection. A 6-month
follow-up study of 377 women attending family planning clinics in the United States,
Mexico, and the Dominican Republic evaluated the contraceptive efficacy of the Reality
condom. The gross 6-month pregnancy rate was 15%. Pregnancy rates were lower among
US women (12%) and among women who reported perfectly (i.e., correct and consistent)
use of the device (4%). Use failure was frequent during follow-up. Although the study
group consisted of women who were engaged in mutually monogamous relationships and
who had agreed to use the female condom as their primary contraceptive device, only
36% reported perfect use.

A barrier to effective testing is that although HIV testing is widely used throughout the
world, many laboratories in developing countries lack the capability for effective,
consistent, and accurate testing. Capabilities vary, depending on resources provided by
ministries of health, national programs, local governments, and nongovernment agencies.
A spectrum of capabilities ranges from excellent facilities, as noted in large testing
centers such as the Red Cross, to poorly funded local hospitals and clinics where
infrastructure, reagents, equipment, and accurate testing are essentially nonexistent. In the
majority of laboratories outside large facilities in major cities, improvement and
assistance are badly needed.

Effective laboratory capabilities in most developing countries are hindered by a lack of

formal programs to educate laboratory technical staff, less than optima infrastructure, and
poor quality control. It is apparent that individuals who have not received formal
instruction or who are not working under optimal conditions could be reporting a
significant number of inaccurate results. Inaccurate results, often due to technical or
transcriptional errors, are common and preventable.
Industrialized countries have been fortunate in having the capacity and resources to
screen all transfusion-targeted blood for HIV antibodies and antigen. Currently in the

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United States, the testing of blood for HIV antibody and antigen has substantially
decreased the risk of transmission of HIV through transfusion.
In summary, barriers to effective testing systems can generally be classified into four
categories: (1) lack of sufficient reagents and equipment, (2) poor infrastructure to
support systems, (3) insufficiently trained and educated personnel, and (4) lack of
implementation of essential quality assurance/quality control measures. Central to these
barriers is a lack of sufficient resources, primarily financial.

2.1. Condom Promotion Programs in Southeast Asia

One hundred percent condom use programs seek to address structural barriers that reduce
the efficacy with which sex workers ensure condom use by their clients. The decision to
use a condom is often outside the direct control of a sex worker. Introducing 100%
condom use programs support prevention by changing the context within which condom
use is negotiated and makes condom use a shared responsibility of brothel managers,
clients and sex workers. Successful 100% condom use programs have been implemented
in the US, Australia, Europe and at the provincial level in several countries in Asia,
including Cambodia (in 12 provinces), China, Lao PDR, Burma, and Vietnam, 14
although many of these have yet to be evaluated thoroughly. In 1998, Thailand initiated
the first nationwide 100% CUP, resulting in a highly significant reduction in HIV
prevalence rates among SWs and their clients. Sex worker was (and remains) illegal in
Thailand. Rather than trying to suppress sex work, which would not curtail demand but
rather drive the industry underground and make prevention efforts more difficult,
officials opted to take a harm-reduction approach by encouraging safer sex through
condom use.

The 100% CUP in Thailand was implemented as a result of extensive collaboration

among different governmental sectors and those who influence the sex industry: police,
brothel owners, SWs, and clients. An important component of the program involved
placing responsibility for compliance with the CUP on brothel owners and clients, rather
than on SWs only, who are not always successful in convincing clients to use condoms.
Compliance was monitored regularly through STI incidence among SWs and clients, HIV

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rates among SWs, and condom distribution. SWs were provided with free or reduced
price STI checkups and treatment. Men attending STI clinics were routinely asked which
brothels they had visited; these brothels then were visited by public health staff to
reinforce the program and provide any needed information. Brothels found to be the
source of repeated STIs could be fined or closed by the police—although it appears that
these sanctions were rarely applied.

One important component of the program was its coverage of a wide geographic area,
which limited the ability of clients to visit a competing brothel where condom use was
not required. Implementing the CUP in a wide geographical area also was important in
terms of compensating for the limited exposure of SWs to HIV prevention programs and
peer outreach messages. SWs are a highly mobile group when an HIV program is
initiated, not all SWs will benefit. One research team in Bali, in a study testing
interventions to increase condom use, found a 50 percent turnover every six months
among SWs. While providing behavioral and medical interventions to SWs did increase
their knowledge about HIV and STIs, as well as their ability to ask clients to use
condoms,19 higher condom use requires cooperation of the clients and constant outreach
efforts to ensure that all SWs new to a particular area are covered by the program. The
Thai 100% CUP, by focusing on clients and brothel managers, compensated for the lack
of exposure of all SWs to high-quality condom use programs.

Other critical components to national scale-up in Thailand were reliable surveillance data,
political commitment, a good network of STI public health clinics, and nongovernmental
organization (NGO) capacity to work with and on behalf of the MARP. Condom use
program activities were integrated into the responsibilities of a number of different
departments or units at the public health and infection disease divisions of provincial and
local governments rather than by the creation of a new vertical program.

This helped to contain costs, produced a sustainable program, and provided sufficient
staffing to support the required activities. Condom use programs in other countries have
adapted various components of the successful Thai model. Although there is not a “one
size fits all” approach to the 100% CUP concept, a common strategy underlies all

20
programs: the mobilization of local authorities to create an environment in which SWs
can refuse unprotected sex.
A multi-country report in 2004 by the World Health Organization Southeast Asia
Regional Office (WHO SEARO, 2004) found that 100% CUP did not require the
involvement of every ministry or level of government, but rather the engagement of a
group of actors directly involved in or affected by a CUP, including the following:

 Local community, political, business, and professional leaders;

 Technical and professional staff from government agencies, especially local
administrators of health and police/public security;
 Representatives of the sex work industry, especially establishment
owners/managers and SW associations or peer educators; and
 NGOs, especially those involved in condom promotion or condom social
marketing programs.

Operations research that monitors the perception, attitudes, and concerns of communities
and stakeholders implementing a CUP is also essential for successful adaptation and
eventual scale-up of condom use programs.

The HIV pandemic has prompted massive efforts to promote condom use. The promotion
emphasis has been on high risk behaviors including pre-marital and extra sexual
relationships and a fair degree of success have been achieved in Cambodia. However,
needs of youths have been neglected despite the fact that in severe generalized HIV/AIDs
epidemic, many infections occur within marital relationships, either because of prior
infection by one partner or because of the infidelity after marriage.

In Cambodia, one organisation conducted “klahan campaign meaning bravery” to lobby

condom use among marital relationship as a contraceptive method. Also, this
organisation launched social marketing program on number one condom and ok condom.
Number one condom was available only in high risk places especially in brothels, while
ok condom was launched in 2004 to attract the users among spouses as a contraceptive
method. Two different surveys on trusting relationships were conducted after a year of

21
campaign (one study targeted sexually active men and another study targeted karaoke
girls) the results of this studies found that most of sexually active men and karaoke girls
have multiple partners outside marriage and level of using condom with those partners
was high but the tendency to use condoms with their spouses was limited. The reasons as
to why low condom use between marital relationships were not told.

Still, countless studies have tried to find out the factors influencing the limited use of
condoms among the youths. World research survey has found that the main reason given
for non use of condom is “l trusts my partner”. Likewise, there is an inherent difficulty in
discussing ones sexual history, disease with a trusted partner especially with spouses.
Trust can “blind” partners to the risk of HIV/AIDS (longfield et al. 2002).

However, it should be noted that low condom use does not necessarily mean high levels
of infection, especially if the couple are uninfected at the time of marriage and remain in
monogamous relationships. This situation is ideal but difficult to fulfill in countries
where married couples have sex outside marriage other than their partners.

Another survey was conducted among high risk groups ( karaoke workers , beer
promotion girls , tax drivers) with a total of 4105 sample size in 10 provinces found out
that more than half of men reported premarital sex. Consistent condom use with sex
workers continues to increase over time but remains low in regular partners. Trusting and
lack of sexual pleasure were the main reason for non use of condom with the regular
partner.

Cultural obstacles are also one of the main factors which refrain women from proposing
condom use. A study on power relationship in marriage (India) which was conducted by
United Nations development fund for women (UNIFEM) in corroboration Indian
ministry of women affairs in 2005 found that married women in India do not fell
comfortable to talk about sexual issues with their partners. These issues include the use of
condom to protect themselves and their new born children from HIV. Moreover, many do
not fell able to refuse sex with their partners, even though they know their husbands are
engaging in risky sex behaviors outside marriage.

22
This proposal examines sociocultural expectations of sexual behavior and the reasons
why lack of condom use may be logical to married heterosexual couples in India. Married
women who report monogamous sexual relationships with their husbands are at high-risk
group for HIV infection in India. Based on the public health model and a population-
based perspective on HIV infection prevention, this study illustrates the underlying
mechanisms that link the role of women in society, holistic health beliefs, and cultural
beliefs about the transmission of HIV with the precursors to nonuse of condoms. I
conclude that promoting condom use requires an emphasis on family health, not only as
contraceptives. Challenges for reducing the social stigma and developing a
comprehensive policy on HIV prevention and AIDS treatment and care are discussed.

In developing countries, the prevalence of condom use among married women of

reproductive age is between 2% and 6%; about half of countries surveyed are below 2%
in the other half. In some countries where overall use of contraceptives is low, condoms
account for a substantial proportion of all methods used. In Cameroon, Ghana, and
Zambia, for example, fewer than 4% of couples use condoms, but condoms account for
more than 10% of all contraceptive use.

Globally, the percentage of married couples using condoms for family planning appears
to have declined slightly during the past decade. In India the prevalence of condom use
fell from about 5% in 1988 to about 2% in 1994 .In some countries; however, condom
use has increased. In Bangladesh and Vietnam, for example, the proportion of couples
using condoms for family planning rose about three percent between the late 1980s and
mid-1990s (541). Levels of condom use within marriage increased a few percentage
points in Brazil, Colombia, Costa Rica, and Peru and rose in Jamaica from 9% to 17%.

Use of condoms with multiple partners, the number of people, whether unmarried or
married, having sex with "no regular" partners—that is, sex partners other than their
regular partner—appears to be substantial. In Burkina Faso in 1992, for example, about
three-fifths of men and one-third of women aged 15 to 24years reported having non
regular partners. In Papua New Guinea in 1994 about 15% of men and 12% of women

23
aged 15 to 49 reported having non regular partners. In the Czech Republic one-third of
men aged 15 and over reported having non regular partners (266).

In some countries recent surveys among people with non regular partners show high
levels of condom use. In Uganda, for example, of the 25% of men and 13% of women
aged 15 to 49 have non regular partners, almost two-thirds of the men and half of the
women used a condom with their most recent partner. In Cuba, of the 21% of men and
13% of women have non regular partners, more than half of the men and more than one-
third of the women reported using a condom with their most recent partner. In Latvia,
where such use was most widely reported, of the 20% of men and 10% of women aged
15 to 49 have sex with non regular partners; over two-thirds used condoms

In Kenya, a qualitative study of 9 communities found out that women concerns about
having good character often prevented them from condom use. If a woman was to
discuses condom use, her good character and fidelity would be questioned. Also, this
study was carried out in Tanzania; found out that married women said that they could not
talk with their husbands about sex for fear of being accused that they learned about sex in
extramarital affairs (marshalyn, 2005).

Also, in the quest for long term security, a woman may feel pressured to submit to her
partners demands because she fears he may leave the union. In such relation, there isn’t a
favorable environment for the woman to assert her demands about how she wants the
sexual experience to precede (Hilary, 2003) a study in sub-Saharan Africa in 1996, with
1936 respondents in Zimbabwe, showed there is little discussion about condom use in
stable unions as only a fifth reported that they regularly talk about condoms with their
spouses or partners. It was also found that bringing the subject of condoms to a partner
might result into divorce, abandonment or physical abuse (valentine, 1996).

Low level of education is thought to be another factor influencing the low level of
condom use. There is no existing study on education associated with condom use among
married women yet. However, to my knowledge, married women know less than men
about HIV/AIDS is transmitted and how to prevent it.

24
Financial dependence also prevents women from proposing condom use with their
spouses. a qualitative study in Rwanda in 2005 among 150 married women support this
notion “very often there is unequal negotiation power because she may be financially
dependent on the partner which creates an imbalance of power relationship when it
comes to sex and this prohibits women from asking for what is right to them
( marshalyn , 2005).

1. F, Stutz ST, summer matter D, et al. Six years of promotion of condom use in the framework of the National Stop
AIDS Campaign: Experiences and results in Switzerland. International Conference on AIDS 1993, Berlin, Germany
Abstract no. WS-D27-.

2.2. TRANSMISSION OF HIV/AIDS

Sexual intercourse is the most common way of contracting STDs (HIV/AIDs).

Unprotected receptive sexual acts are riskier than unprotected incentive sexual acts.
Transmission STDs through unprotected anal intercourse is more likely than through
unprotected vaginal intercourse or oral sex. Sanches et al. (2006) 14% of men who have
unprotected sex with men have higher chances of contracting STDs than having
unprotected sex with a female partner

Transmission from women to men is less than from men to women. Women also have a
higher biological susceptibility to HIV infection. The structure of women’s sexual organs
exposes them more readily than men to HIV and other sexually transmitted diseases.
Poverty and changes in the society make women particularly liable to the infection. Sex
tourism has increased the spread of the infection, which is increasing in concurrence with
other sexually transmitted diseases (Icovics 1998, Holmström 2002, Aitken 2005).
According to Johnson & Laga (1988) a major form of transmitting HIV is through
heterosexual transmissions in Sub-Sahara. The critical factors are the number of partners,
sex prostitutes, sex with infected partners and sexual diseases.

In the developing countries the spread of the heterosexual HIV is heterogeneous. Factors
that explain the wide diversity of the prevalence of HIV in different countries may be
underdetermined. International aid organizations are focusing their activities mainly on

25
women rather than on men. O’Farrell (2001) the results showed that the ratio of female to
male HIV transmission in the developing countries compared to that in the developed
world was 341:1. For male to female transmission the rate was 2.9:1. Enhanced female to
male HIV transmission in male core groups is a critical point among the heterosexuals. In
addition there is a need for an increased emphasis on HIV prevention activities in men to
decrease their susceptibility in the developing countries.

2. Joint United Nations Program on HIV/AIDS, press release. 28 November 1996.

3. White House 1997 National AIDS Strategy. National AIDS Policy Office.

The majority of mother to child transmissions (50–80%) can occur in uterus during the
pregnancy or in trapartum at childbirth. Since 1998 pregnant women in Finland have
been given the possibility to get tested in a local health care centre. Breast feeding has
been regarded as the most important cause of post-natal infections. The risk varies
between 14–29%. The risk of transmission by breast feeding is highest during the first six
weeks after the birth (Holmström & Leinikki 1997, Vuorenkoski et al. 2002). Becquet. &
Leroy (2007) observed that breastfeeding which is wide spread and prolonged in Africa
causes many HIV infections and thus reduces the efficacy of postpartum interventions.

Some of the infected individuals may not get any symptoms at all. After the stage of
Acute HIV infection, a period will follow; this stage is called Clinical latent HIV
infection. The latent stage may take from some months to several years. During that time
the individuals will have a normal physical ability to act and work. Yet, an HIV positive
person is a source of transmission even during the latest phase with no symptoms (Korte
et al. 1993, Holmström & Leinikki 1997).

LAS (Lymphadenopathy syndrome) are a stage where a few symptoms appear indicating
that the virus is active in the lymphoid organs. The stage of LAS may take several years.
When CD4+T cells are below the critical level and the immunodeficiency of the HIV
infected person is at a low level, the first symptoms include unexplained weight loss, oral
ulcerations, respiratory infections and rash. Here the infection has progressed to the stage

26
of ARC (Aids related complex). The HIV infection starts to affect the ability to act and
work. The resistance against common diseases is lost and the common opportunist
infections and tumours are included in the stage of AIDS. When the level of CD4+T cells
decreases there is a risk of becoming infected by some of the opportunist infections.
Pneumocystis carinii – pneumonia is the most common opportunist infection. Some of
the infected individuals will have difficult tumours. The most common one is Kaposi’s
sarcoma (Korte et al. 1993, Oksa 2007)

The route of transmission had Psychological and sociological effects. The psychological
and sociological effects of HIV are also remarkable from the point of view of the
individual and the society, as well as from ethical and political aspects. Socially HIV is
associated with images and feelings of guilt, sexuality and death. The society associates
homosexuals, bisexuals, users of intravenous drugs, prostitutes or often simply
foreigners, deviant or otherwise odd people. The discussion of taboos, originally, AIDS
was associated with the taboos of death and sexuality as a sexually transmitted disease.
Sexuality in itself is combined with shame and guilt, death and fear. Hence AIDS has to
be a punishment of God to the patient for his/her sexual misconducts, because God is
nature, “the normal order of life” (Lindquist 2002).

Due to incorrect understanding and inadequate knowledge, people have thought that
homosexuality or the use of intravenous drugs may be the reason for AIDS. There are
two possible explanations, AIDS as an illness is a punishment for acts that are regarded
as wrong, sins and unnatural. It may also be thought that homosexuals and drug users are
people who are dangerous to others. If these people are foreigners, perhaps also of a
different race and religion, the image of an enemy grows stronger. A taboo is used for
generalization, isolation, and controlling. Psychologically taboos act as a channel for
many fears and feelings of guilt other than those which they are concretely concerned
with (Lindquist 2002)

27
People with HIV and AIDS are often reluctant to be open about their HIV/AIDS status,
thus increasing their feeling of isolation. In communities where HIV is less common
people with HIV often come from minority groups, such as drug users, men who have
sex with men or sex workers. They may have less supportive networks and face added
discrimination if they are suspected of being HIV positive. Many patients have to live in
discrimination even in high prevalence countries where HIV affects nearly every member
of the population (UNAIDS 2000).

2.3. PREVENTION OF HIV AND AIDS

The goal of preventing HIV/AIDS is to help an individual to take responsibility for the
well-being and health of their own as well as that of their partners. For a successful
prevention programme political will and commitment is needed. The UN Population
Fund, UNFPA, has listed sixteen ways of preventing HIV/AIDS (Kiviluoto 2002). The
factors have also been considered important for the prevention by other studies.

The young everywhere need information as well as open and comprehensive, non-
moralizing sex education. The provision of sexual education should also support the self-
esteem and life skills of the youths. The media and the way the sexually transmitted
diseases are informed of and dealt with in the media have an influence on the attitudes
and the common reaction of the youths regarding HIVIDs (Holmström 2002).

The prevention of infections among pregnant women and the prevention of transmission
of actual infection to foetus and neonates are important both in the industrial and in the
developing countries. Besides drug therapy, mother-to-child transmissions have been
prevented in the rich industrial countries by means of section births and by refraining
from breast-feeding. The risk of breast-feeding varies from 14% to 29% depending on
how much virus the mother has in her blood (Vuorenkoski et al. 2002, Lounamo 2007).

28
Change in the sexual behaviour is focused on the counseling on prevention at the
individual level. Routes of transmission and methods of prevention are also stressed.
Prostitution is one of the most important sources of infection in many countries. The
amount of sexually transmitted HIV infections can be lowered by decreasing the number
of sex partners, avoiding sexual contacts with individuals who have several partners and
also by having safer sex. Prevention and treatment of other sexually transmitted diseases
is important since the diseases increase the risk of becoming infected. An important
factor in the prevention of HIV is to increase the opportunities of women and children to
refuse to be engaged in risky sex and other demands for contraception.

According to Fako (2006) the importance of sexual activity, the number of partners,
happiness with life in general, level of attachment to father and physical fights with other
children were identified as the social and psychological predictors of willingness to be
tested for HIV. The study shows the importance of continued education in voluntary
counseling and testing among active young people, especially those from poorer
backgrounds in the rural areas (Kiviluoto 2002, Roark et al. 2005).

2.4. KNOWLEDGE/AWARENESS OF HIV/AIDS

A cognitive component of attitude, knowledge describes what people think. Knowledge

and information about HIV/AIDS have been shared through media and several
information sources. Requirements for sexual education and study material on HIV/AIDS
and other sexual disease are continuously growing. In the 1980s and 1990s wide sexual
education related campaigns were organised for the entire population in Finland. At the
same time the Ministry of Social Affairs and Health began to send all the youngsters aged
16 (later also to those aged 15) a magazine of sexual education with a contraceptive and a
letter to the parents. It has not been sent since 2004. The number of infections has
increased from 126 new cases in 2004 to 189 in 2007. In order to correct the lack of
information the Ministry of Social Affairs and Health has compiled the first national
action programme 2007–2011 in Finland for the promotion of sexual and reproductive
health.

29
Sexual and reproductive health studies are included in the health education studies and
curriculum of the comprehensive and vocational schools (Ministry of Social Affairs and
Health, 2007). In Kenya, the University of MOI has a policy of HIV/AIDS. It includes
HIV/AIDS education, rights and responsibilities of students and staff and a possibility for
voluntary testing at the university (MOI University HIV/AIDS Policy, 2006).

The study by Wody (2005) in Nigeria concerned the secondary school students’ attitudes
towards HIV/AIDS. The students’ median age was 19 years. One third to half of the
respondents believed that a person may become infected through mosquito bites; they
also believed that an infected teacher or a student should not be allowed to continue
teaching or attending school. The students had not had discussions about HIV or AIDS
with their boy friend or girl friend, nor their parents. In the study of Lefkowitz et al.
(2003) adolescents who discussed safer sex with their mothers tended to be older, less
religious and have more educated mothers than those who did not

In the study of Soet et al. (1997) the knowledge, attitudes and sexual practices of Asian
college students were investigated. The results indicated that the male students were more
sexually active, more likely to use condoms and they had less positive attitudes toward
abstinence than did the female students.

2.5. RISKY HEALTH/SEXUAL BEHAVIOUR AND PREVENTION AGAINST

HIV/AIDS INFECTION

Smoking is considered to be the most addictive substance of all and a stepping stone to
other substances, including narcotics. It almost always promotes other drug use. In a five-
year-long follow-up study of Salonen (2003) smoking seemed to decrease and cannabis
seemed to be an increasing problem among both the first-year and the fifth-year
university students. More than half of the heavy smokers (56.1%) reported some cannabis
use in their fifth study year. Cannabis was found to be the most common initial substance
in the progression of narcotics abuse. The results also showed a strong relationship
between smoking and the use of alcohol. Almost one third (31%) of the heavy smoking
male students and 17% of the heavy smoking female students were also heavy drinkers.

30
According to Kunttu (2004) university students who were heavy drinkers were also
smokers and tried or used drugs more than other students.

In this study the results indicated that almost 70 per cent of the students replied that they
had not smoked at all during the last month and 92.0% of the Kenyan students were non-
smokers. More than sixty per cent of the students (64.9%) never drank alcohol. There
were no large differences in the use of alcohol between the male and the female students.
More than ten per cent of the respondents reported that they had used drugs. The female
students had used amphetamine, ecstasy and LSD more often than the male students. One
fifth of the male respondents informed that they had used cannabis, hashish and
marijuana while the corresponding percentage of the female students was 14.5%.
The results showed that it was common for the respondents to be single during their first
study year. Nearly two thirds of the students of Moi University responded that they did
not have any sexual relationships. More than forty per cent of the students at Oulu
University had not had any sex during the previous month. The result was similar with
the study of Nikula et al. (2007) where the result showed that it was common for younger
men to stay single and have multiple partners.
The respondents at the University of Helsinki were more active; they had sex two to three
times a week or even more. Two thirds of the respondents who reported religion to be
very meaningful had no sexual relationships. More than eighty per cent of the students of
Moi University (85.5%) and of the universities of Oulu (17.5%) and OUAS (14.8%)
replied that religion was very meaningful for them. According to Kontula (1991), religion
was named to be one of the main factors influencing the sexual behaviour of the
youngsters. Religion has also been regarded an important factor of the ethical dimension
in human sexuality by Greenberg et al. (1993). Smoking and the use of alcohol have no
correlation with either the frequency of the sexual activity or the number of partners.

2.6. SUCCESSFUL STRATEGIES IN OTHER DEVELOPING COUNTRIES

The elimination of infected blood through implementation of blood screening for HIV
has saved countless lives throughout the world, particularly in Africa. In Zimbabwe,

31
between 1986 and 1990, 3.4% of donations were found to be HIV positive; had these
units been transfused, more than 10,000 persons could have become infected. Similarly,
in Rwanda between 1986 and 1990, 5.6% of donors were infected, 12 and over 15% of
blood donors in Uganda were positive for HIV in the late 1980s. These statistics
exemplify the high prevalence of HIV in Africa and the gains in HIV prevention of
implementing a low-cost mechanism such as HIV testing.

Since the application of more selective standards for recruitment of blood donors,
infection rates among donors in Africa have decreased even as prevalence rates among
the general population increases. This is exemplified in Rwanda, where HIV infection
among blood donors decreased from over 13% in 1985 to about 2% in 1990, while
infection rates rose in the general population. In Uganda, better selection of donors has
resulted in a reduction of HIV-positive blood donors by 50% within 3 years. In Côte
d’Ivoire, West Africa, excluding 31% of donors could have eliminated 73% of HIV-
infected donations.

A very effective mechanism for decreasing the risk of HIV-infected donors through better
selection has been implemented in the country of Myanmar. Here, a system of recruiting
repeat donors who have been previously tested and found to be HIV-negative has resulted
in a decrease of HIV infection in blood donors from 13% in 1993 (50% repeat donors) to
1% in 1996 (90% repeat donors). This excellent strategy for enhancing blood safety is
essentially without cost. Similarly, the use of voluntary blood donors has proven to
decrease the risk of HIV positive blood. Rates of infection in voluntary donors were less
than half of that from blood donors recruited amongst patients in hospitals in Kenya and
Uganda.

2.7. RECOMMENDATIONS, EDUCATION AND TECHNOLOGY TRANSFER

Given that many laboratories in developing countries are geographically isolated and
communications are expensive, updated information and new regulations are difficult to
distribute. In addition, inadequate resources may limit reproduction and distribution of

32
informational materials. As described for the Philippines, periodic visitations by
reference laboratory personnel can help to address this need. Materials, including books,
newsletters, and checklists can help provide individuals with information that can
improve their testing efforts. External means for education, including national and local
teaching workshops, can provide teaching materials and instruction. The WHO, the
World Bank, and the World AIDS Foundation have all participated and funded
international professionals to provide information and technology transfer workshops in a
number of countries. To argue these workshops, appropriate books and manuals that are
available on HIV testing and quality control have been provided. Assistance from such
organizations must be aggressively pursued.

2.8. PREVENTIVE HIV TESTING AND COUNSELING

The primary goals of VTC are to prevent spread of HIV through heterosexual contact and
maternal-child transmission. Secondary prevention attempts to reduce the morbidity of
HIV infection through early or prophylactic treatment of HIV-infected persons; examples
include antiretroviral triple drug therapy and, of greater relevance in developing
countries, tuberculosis chemoprophylaxis and possible future therapeutic AIDS/HIV
vaccines. Although secondary prevention may become increasingly important in
developing countries, should affordable treatments become available, this discussion is
limited to the role of VTC in primary prevention.

Most primary preventive VTC involves HIV-negative or asymptomatic HIV-positive

persons identified through HIV testing centers or through linked testing of blood donors,
hospital inpatients, and outpatient clinic visitors. VTC may be provided confidentially
(identifiers are recorded but steps are taken to ensure that knowledge of the test result is
limited) or anonymously (where the test results are number coded and the client’s
identifiers are not recorded). The advantage to anonymous testing is that the client is
protected from any harm that might come from their test results being disclosed to others,
and many people are more likely to seek testing using anonymous rather than confidential
services.

33
Persons who are tested for reasons other than their own request may or may not be
offered the opportunity to know their test results, depending on the circumstances. Blood
transfusion centers may not see prevention of heterosexual and maternal transmission as
their mandate and may not want to offer VTC if it encourages high-risk groups to donate
blood. Similarly, health care staff often tests patients as part of a clinical evaluation or for
research purposes. Ideally, for the process to be truly voluntary, informed consent should
be obtained and systematic pre and posttest counseling provided, but—ethical mandates
notwithstanding circumstances may not allow it. This is easy to imagine in a hospital
public ward with two patients per bed; there is little opportunity for a confidential
discussion and health care staff are already overwhelmed.

A similar situation exists in many outpatient settings, where the large number of patients
may reduce the average consultation time to 5 minutes or less. If VTC were shown to be
effective as a Preventive measure in these settings, it might prove to be cost-effective,
since the cost of the HIV test itself is already paid (either subsidized or paid for by the
patient) and only counseling staff would need to be added to existing services. This
would have the added advantage of allowing HIV testing to proceed in a manner more
compatible with ethical guidelines.

2.9. SUPPORTIVE SERVICES

Supportive counseling for AIDS/HIV patients and their families attempts to reduce the
psychological and social morbidity associated with HIV disease. Emotional support to
reduce stress and promote acceptance of the situation may be given by health care staff or
b y social service providers, and may be offered to individuals, couples, families, or in
support groups. Practical assistance includes the provision of social services such as food,
clothing, and medicine; home health care; housing, child care, and school fees;
employment assistance; and legal advice regarding discrimination, wills, and insurance.
Integrating supportive services with testing services may reduce the dramatization of
HIV/AIDS in society and improve the quality of life of participants. Training programs

34
sponsored by the World Health Organization (WHO) and other organizations have added
supportive counseling to the skills of social workers and nurses involved in health care.
In many countries, supportive counseling for emotional well-being is not a traditional
intervention, however, and given time constraints, a greater emphasis is often placed on
practical assistance. The role of health care personnel in these circumstances is often to
liaise with agencies outside the health sector and provide appropriate referrals.

Religious organizations have traditionally provided material assistance for the indigent
and were quick to respond to the needs of AIDS patients. As an example, in Rwanda,
Caritas (a Catholic NGO) was the implementing agency for a WFP/UNDP/WHO
psychosocial support project, including a food distribution program targeting families
stressed by HIV disease. One study in the capital of Rwanda found that HIV-positive
women who had been counseled by a clinic based Social worker initially considered the
social worker to be their primary source of emotional support. Two years later, these
same women viewed the church as far more important in that role. Where health care
staff is overwhelmed with other responsibilities, referral to church-based or other NGOs
may be a practical way to provide material and emotional support following initial pre
and posttest HIV counseling.

While it is important to integrate preventive and supportive services, it is essential to

distinguish between the needs of a symptomatic HIV-positive clients and those of
chronically ill patients. In the recent enthusiasm for provision of “care and support” for
HIV, the negative consequences of some practical assistance programs have, at times,
been overlooked. Creating service delivery systems that specifically target HIV-positive
persons can create a black market for HIV positive Test certificates, motivate the very
poor and desperate to become HIV positive in order to qualify, and breach patient
confidentiality because the assistance is usually very visible.

Furthermore, most HIV-positive persons who attend VTC centers are asymptomatic and
do not require additional services beyond the expected routine of pre- and posttest
counseling. Therefore, it is more helpful and less harmful-to prioritize very ill patients

35
and their families when developing supportive services, and it is most efficient to have
those services emanate from hospitals and clinics rather than VTC centers.

4. Becker J. Integration of HIV/STD prevention and family planning: Lessons learned by IPPF/WHR and
family planning associations in Honduras, Brazil and Jamaica. Presentation to USAID Population Health

and Nutrition Center, STD continuing education series. September 12, 1996.

3.0. INTERVENTIONS FOR COMMERCIAL SEX WORKERS AND THEIR

CLIENTS

Valences of HIV-1 in female commercial sex workers (CSWs) of over 80% in sub-
Saharan Africa 40% in Asia, and up to 20% in South America are now common. In the
Pumwani district of Nairobi, CSWs who are initially negative have a 42% risk of
becoming infected with HIV-1 by the end of 1 year of sex work, despite prevention
intervention programs. CSWs are at the core of numerous sexual networks, because of
their high number of sexual partners, and have a much higher risk of sexually transmitted
disease (STD) and HIV infection (and subsequent transmission) than the general
population. Studies in northern Tanzania revealed an HIV-1 prevalence of 73% among
CSWs, compared with up to 3% among blood donors in the same district.Given the well-
documented synergy between STD and HIV infection, HIV transmission models have
projected that treatment of STDs in a core group of female CSWs would lead to the
prevention of approximately 10 times more cases of HIV than treatment of the same
number of STDs in women in the general population.

This daily danger of HIV infection has become a fact of life for almost all CSWs in
developing countries. It is within this context that health and social welfare workers
attempt to decrease the risk of HIV infection for these women and to measure that
decrease in order to direct further intervention efforts. This proposal describes the
environment, strategies, and effects outlined in reports of evaluated HIV prevention
interventions aimed at CSWs in developing countries and offers perspectives on future

36
directions. It is not intended that the list of interventions examined be exhaustive, but
rather that features of notable interventions be highlighted.

3.2. LIFESTYLES OF COMMERCIAL SEX WORKERS

Female CSWs in developing countries are characteristically poor, have little formal
education, and live in a setting where gender inequality dictates that women have little
power within their sexual relationships. Their goal is almost always survival. A typical
example from Africa is that of Nairobi CSWs, whose earnings of approximately US$3 a
day are comparable to the earnings of a manual laborer. Young women entering sex work
in their teenage years fall into two broad categories: the rural girl who migrates to the city
to find work and make money for herself and her family, and the urban girl from the
slums who has no other prospect of employment and who may be the daughter of a sex
worker herself. These young women often have had a child outside marriage or are
estranged from their families for other reasons. Some girls are sold into indentured
service by their families. Older women, in their 20s or over, are commonly divorced or
widowed and have several children whom they must feed and try to educate. The death of
husbands from AIDS has already forced many widows into sex work, creating another
dangerous synergy between HIV and sex work.

The clients of female CSWs in developing countries are often men who live away from
home. Many live in a culture where sex before marriage is not socially acceptable, with
the result that single men visit CSWs. Because of the economic circumstances of the
women, their low social standing, and the large number of women selling sex, the client
of the sex worker retains the power in the sexual relationship. Combining risk reduction
with economic survival can thus be difficult or impossible for CSWs without the consent
of clients. If a client visits the same sex worker on several occasions, the nature of the

37
relationship often changes: the client may come to view the sex worker as a girlfriend and
may help her subsistence costs rather than paying a fee per sex act. This financial and
emotional shift in the relationship is disadvantageous to both partners, as the man feels
more secure not to use a condom and the woman is more dependent and less able to insist
on condom use.

One aspect of the client-sex worker relationship, which is not often discussed, is the
emotional needs of the client. It is not safe to assume that men only visit CSWs for sexual
gratification. Many of the young men who visit CSWs have moved away from home to
find work. They are often socially dislocated, suffer from a sense of isolation, and live in
bachelor groups under brutal conditions. Sexual contact may be the only form of human
tenderness to which they have access. This emotional need for intimacy, which they
cannot admit to themselves or their peers, may contribute to unsafe practices, such as
offering to pay more for sex without a condom.

It is important to remember that sex work followed the same pattern during the period of
industrialization of North America and Western Europe, when there was widespread
poverty, large-scale movements of men to work on building national infrastructures, and
many thousands of CSWs in Victorian London. While the current studies relate to the
countries and cultures of the South, it needs to be recognized that sex work has no ethnic
basis, and its magnitude at any given time, in any given place, is usually a function of
socioeconomic circumstances.

Sex work, or prostitution, is known as the oldest profession. It is also the profession that
is subject to the most draconian legislation and pejorative name calling. In most
countries, sex work is illegal. Yet laws banning sex work usually do not eliminate it; they
typically serve only to increase the corruption of public officials and police, the
oppression and degradation of CSWs, and the creation of additional barriers to STD and
HIV control. Nonetheless, it is also true that in some countries official prohibition
coexists with a spirit of tolerance and regulation for the public good.

38
There are several ways in which sex workers can meet their clients: independently or
through broker-mediated (“protected”) encounters. Broker mediation and protection can
range from relatively friendly to violent and abusive. This range is best illustrated in
brothels (“direct” sex work), where CSWs may have an arrangement akin to a hotel,
where they rent rooms and enjoy collective protection for a percentage of their earnings,
or it may be a situation where the women are prisoners and the brokers are the guards.
The brokers may be male (pimps) or female (madams). The pimp usually has more of a
controlling influence over the sex worker and often exercises and cements his domination
by also being a regular nonpaying sex partner.

Other women may work in establishments such as bars, discos, or massage parlors
(“indirect” sex work), where they supplement their income by selling sex and are subject
to varying degrees of regulation. In some countries in sub-Saharan Africa, home-based
CSWs are common; they work independently by sitting outside the door of their houses
in the slums and waiting for clients, mostly during the day. Sometimes girls who still live
at home also ménage in sex work without the knowledge of their family, usually with the
help of a broker who arranges meetings with clients. Of all the categories of sex workers,
it is the street workers, who usually have no premises to work from and are very visible,
who tend to be subjected to the most harassment and abuse.

Male CSWs, who are typically engaging in commercial sex with other men, often are
even more stigmatized than female CSWs, but they are far less common, and the power
relationship between CSW and client may be less clear-cut. Male CSWs who service
men, such as young boys forced into sex work due to poverty or homelessness, may not
consider themselves homosexual. Their clients may seek out CSWs because of strong
cultural taboos, which prevent men from openly admitting sexual interest in other men.

Male CSWs are more common in South America and parts of Asia than in Africa;
sometimes they form culturally distinct subgroups, such as the transvestite of Indonesia
and of south India, who often initiate young men who do not consider themselves
homosexual. While male CSWs contribute relatively little to the huge burden of HIV

39
infections in developing countries, they may have served as entry points for HIV into
communities, through bisexual bridges into heterosexual networks. An analysis of
HIV/AIDS surveillance data and 60 HIV-1 surveys conducted in Latin America from
1987 to 1990, found significant male-to-female transmission from core groups of male
CSWs, via their bisexual clients who were married or had stable female partners.

It is also possible that sex tourists from industrialized nations introduced HIV into
previously uninfected areas through relations with local sex workers, female or male.
Once local transmission is established, however, their continued presence is not
necessary to maintain the epidemic, and now that prevention methods are well known,
tourists are often more likely to use condoms with sex workers than are local residents.

3.3. INTERVENTIONS FOR WORKERS AWAY FROM THEIR FAMILIES

The link between the movement of people and the spread of HIV is one that has been
treated with a great deal of ambivalence. On the one hand, and especially at the beginning
of the epidemic, people in one country after another tried to show that HIV came from
somewhere else, from any country but their own. Stories about an “AIDS-bringing
foreigner” circulated in the press in many countries, the common theme being that
someone from elsewhere, and who was usually of another race, was accused of having
infected members of the local population. On the other hand, and on the other side of the
ambivalence about migration and HIIDs, it is principally in the bodies of people who
move that the virus has been transported from one place to another.’ Several studies, to
be reviewed in this proposal, have traced the development of the epidemic along the
routes followed by people on the move for professional reasons, or have traced the first
AIDS cases in particular regions to the return of people infected as they worked abroad.

It is such workers who reside temporarily apart from their families that are the subject of
this proposal. Some are migrants, people who live as foreigners in countries; others are
ethnic minorities; and still others are nationals of the country in which they are living but
mobile for professional reasons. Findings that discuss HIV prevention among populations

40
of such mobile workers are truck and bus drivers, military personnel, seafarers, miners,
migrant labors, and mobile traders.
HIV prevention and care among migrant populations has been the object of many
publications in Europe and in the United States but published literature concerning
mobile populations in developing countries is scarce. A Medline literature search
performed to prepare this proposal led to a very small number of published articles, and
most of what exists has been epidemiological, focusing mainly on HIV status. For
example, surveys of a population cohort of approximately 10,000 individuals in a rural
sub county of southwest Uganda and along major truck routes in Tanzania have shown
that change of residence is strongly associated with an increased risk of HIV-1 infection.
There is, however, no coherent framework in the published literature for understanding
either the migration or the risk behaviors that may be associated with it: Published studies
rarely address why that might be behind the differences, why people might move, or the
circumstances surrounding risk behaviors.

There were great difficulties for the children of these women, who were without
recognized fathers in a matrilineal society and some of whom in turn entered the circle of
prostitution. The long-term economic consequences of the events beginning in the 1960s
are becoming apparent only now, as women with AIDS return home for medical care and
to die. The unintended consequences of another major construction project have been
described in Lesotho. Reported AIDS diagnoses have risen precipitously in this small,
mountainous country in South Africa since the first case was identified in 1986. One of
the reasons can be traced to the initiation of the Lesotho Highlands Water Project, which
gave rise to an influx of a migrant work force of predominantly single males. Unlinked,
anonymous HIV testing of 486 persons revealed a prevalence seven times higher among
workers than among nearby villagers of the same sex and age. In a concomitant survey,
STD clinic patients knew about HIV/AIDS and condoms, but only 2.4% (including those
who were HIV positive) used them regularly.

In East Africa, male sugar cane cutters have been the focus of an HIV prevention
intervention in Tanzania. These are usually young or middle-aged men who leave their

41
families behind for the 6 months they go to work in the sugar factory. Some set up
household during the season with women from a village near the sugar estate, an
arrangement that appears to have contributed to high STD and HIV rates observed on the
estate.

Another study, also from Tanzania, reports significant changes in roles between husbands
and wives within the last generation. Economic changes make it impossible for men
alone to provide for basic household needs. Income-earning activities for women include
petty trading, some of which involves spending several days away from home, during
which child care is delegated to the eldest child in the family. The subsequent lack of
good parental models could be one explanation for an increase in the problem behaviors
that were rare in the villages only a generation ago. Other studies have examined the
impact of such changes on commercial sex. At one extreme, although prostitution is
illegal, commercial sex is known to be readily available at well-defined urban “scenes,”
and attempts at repressive measures have mainly resulted in moving activities elsewhere.
On the other hand, in a society where exchanges of gifts and money are common, it may
be difficult to distinguish commercial relationships from other relationships between men
and women.

In addition, a decline in social and economic conditions has created HIV risk conditions
for women, especially, for whom commercial sex is among the coping strategies
available. Bar and restaurant workers, for example, may find their wages inadequate for
meeting their own basic needs, as well as those of their children and other dependents.
Even government and other official employees may find their income unrelated to costs
for basic survival needs in urban settings: rent for a single room in a major city such as
Dar es Salaam, for example, amounted in the mid-1990s to a third of the official
minimum salary.

3.4. MIGRANT LABOR IN ASIA

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Singhanetra-Renard provides an excellent findings of why migration occurs in Thailand,
of the complex factors of change that have led to increased mobility, and the decreased
social control that may accompany such mobility. Socioeconomic development and the
creation of new industries have led to an increased need for labor. At the same time there
has been a decline in the need for agricultural labor, and modern transportation and
communication routes have developed. The development of Chiang Mai City, for
example, has brought a flourishing construction industry and a demand for inexpensive
labor, including female and clandestine foreign workers. It has also brought employment
in commercial, manufacturing, and service sectors, more than half of which is also
female.

Several other complex factors have contributed to increased labor migration to cities. The
economic boom, for instance, has given urban elites disproportionately high buying
power, and rapid growth in rural land purchases has meant that agricultural laborers have
become wage workers, making it necessary to send a family member to a city to work.
Strife along Thailand’s borders has created both combatants and refugees. The
replacement of opium as a crop is changing the economy and ecology of hill regions,
forcing upland ethnic minorities to migrate to Low-level for employment. The creation of
newly perceived needs and rapid growth of addiction to heroin, which is not produced
locally and is more expensive, have created debts that must be met by selling resources.
In some cases the only resources available to be sold are daughters—sold into
commercial sex work. For rural women, routes to social mobility include urban
employment, marriage, and education, but a “shortcut” can be found through commercial
sex work. Finally, there has been a lessening of traditional constraints: migration of
young people to Work in cities is one factor that has undermined parental control and
also lessened constraints on pre- and extramarital sex as well as on injecting drug use.

3.5. WORKERS AWAY FROM THEIR FAMILIES

Limited employment opportunities for women in rural areas, but one well-paid
employment opportunity that does exist is commercial sex work: The mean income for

43
commercial sex workers in this survey was ten times higher than for women working in
other industries, or for female accountants, for example. Women working in the
commercial sex industry may provide a major source of income for their families of
origin, and although such work is not socially approved, women engaged in it say their
families need the money they earn. Their earnings may in fact enable their families to live
in better houses and to buy consumer goods.

3.6. TRADING, TRUCKING, AND FISHING ROUTES IN ASIA

As they had in the 1980s, in Uganda and Tanzania, truck drivers in Thailand have
recently become a focus of attention for their possible role in carrying HIV to new areas,
serving as a link between commercial sex workers and the general female population.
Several projects are now getting under way for AIDS prevention along Thailand’s
borders, among traders, small-time smugglers, loggers, fishermen, commercial sex
workers, and tourists. A baseline survey assessing risk among cross-border populations
along the Thai-Cambodian border, for instance, combines both top down and grass roots
approaches, obtaining assistance from government authorities and working with local
informants in close contact with people on both sides of border check points.

Data collection methods are similar to those used in the African studies previously
discussed, mainly involving in-depth and group interviews, and results are also
remarkably similar. Fishermen, for example, have relatively high incomes and few
expenses at sea, and commercial sex is considered to be part of the lifestyle, especially
for young boat crews. As in the African studies, the distinction between various sorts of
commercial and noncommercial sex partners was found to be tenuous, as was that
between minor wives and noncommercial sex partners.

In India, truck drivers have been the object of particular attention. One study found that
in 1990, 3 out of 302 long-distance truck drivers tested were infected and a more recent
article attributes long-distance truck drivers with being significant vehicles of the spread
of HIV/AIDs. Unpublished reports on action research along trucking routes between

44
Nepal, India, and Bangladesh find, once again, that the culture of long-haul truck drivers
is one that expects casual sex, reporting a local saying: “A driver is a driver,” a statement
that is not intended as a compliment. They also point out that drivers have ways of
earning extra cash and are known to have plenty of money available, As in the African
studies, the anonymous climate of border town or truck stop environments is noted, in
which a wide range of people gather away from traditional cultural restrictions and social
pressures.

3.7. HIV PREVENTION PROGRAMS IN ASIA

Most of the studies described above combine baseline research and initial HIV prevention
interventions. A series of such efforts among truck drivers in India was presented at the
1996 international HIV/AIDS conference. One such project takes place 55 km from
Calcutta, on the national highway from southwest India. Some 1200 trucks pass through
every day and must stop for tax clearance; a process that may take up to 8 hours. Baseline
evaluation had revealed extremely low AIDS knowledge and high levels of risk behaviors
among truck drivers and their assistants. Project staff provides treatment of minor
ailments, referrals, HIV counseling, condom distribution, health education, and blood
screening. They also offer drivers a space for rest and relaxation, and accident insurance.
The authors report that over the period of a year the project has become known as a place
where one can come for treatment of “secret diseases.”

A similar model project, which is meant to be replicated, takes place at the border area
between India and Nepal where services had been lacking. This project also involves
outreach in parking zones, as truckers wait for customs clearance. Discussions start with
the health hazards involved in trucking. A clinic has been established for general medical
treatment as well as for treatment and counseling concerning STDs, for truckers as well
as for community people. Efforts have been made to create community support for the
project, and those responsible notes that AIDS prevention may also include providing
accident insurance and offering medical treatment to local children. Evaluation measures
include the number of condoms distributed, monitoring of AIDS-related knowledge,

45
attitudes, and behaviors (the survey shows that over the year from August 1995 to August
1996, a maximum of 20% of the respondents possessed full AIDS knowledge, whereas to
72% had none, and that 46 to 80% had never used condoms), as well as observation of
such qualitative indicators as increase in trust (noting, for example, that truckers who
come for repeat visits to the center often bring several others with them).

A final project in Asia should be mentioned: a baseline survey was carried out among
truckers and maritime workers in Papua New Guinea. The rapid ethnographic assessment
included observations that permitted validation (or lack thereof) of interview data, for
example, about the ways in which potential riders wave a truck down or are smuggled
into sailors’ rooms. The authors note, in common with other authors, that in spite of strict
company rules forbidding passengers, it is common for women to hitch rides with truck
drivers and to pay for the ride with sex. This includes teenagers on school vacations. The
project involves peer education for HIV prevention, and is being evaluated, although
results are not yet available. Outcome evaluations are not available for any of the projects
described. Co-ordination Action Research on AIDS and Mobility has recently started an
eight country participatory action research program in Southeast Asia.

3.8. INTERVENTIONS FOR INJECTING DRUG USERS

During the first half of the 20th century, the use of illicit drugs by injection was so
sufficiently concentrated in one country that it was known as “the American disease.”
(Non injected use of psychoactive drugs, however, occurred throughout the world.) Over
the last three decades, the practice of injecting illicit psychoactive drugs has spread
rapidly. There are now an estimated 5 million persons throughout the world who inject
illicit drugs and this number is probably growing rapidly. By 1996, drug injection had
been reported in 120 different countries and HIV infection in drug injectors in 80 of these
countries. The latter is a substantial increase over the 59 countries with HIV infection
among injecting drug users (IDUs) in 1989, illustrating the extent to which HIV infection
among IDUs has become a worldwide public health problem.

46
In Spain and Italy, injecting drug use has long been the most common risk factor for HIV
infection and AIDS. In the United States; it has been the second most common risk
behavior among cases of AIDS, with approximately 30% of cases reporting injection
drug use as a risk behavior. Over half of the heterosexual transmission cases have
involved transmission from an IDU, and over half of the prenatal transmission cases have
occurred in women who injected drugs themselves or were the sexual partners of IDUs.
In the most recent estimate of new HIV infections in the United States, approximately
half of all new infections in the country are occurring among IDUs. High rates of HIV
infection among IDUs have already been observed in many countries outside United
States and the south such as Argentina, Brazil, Thailand, India, Vietnam, Malaysia, and
Myanmar. In many countries in the developing world, injection drug use has become the
most common risk behavior associated with HIV infection.

HIV may be introduced into a local population of IDUs through a “bridge population,”
such as men who have sex with men and who also inject drugs. This appears to be the
way in which HIV was introduced into the IDU population in New York City. Travel by
IDUs may serve to introduce HIV into local populations, and incarceration of IDUs from
different geographic areas may also contribute to spread of blood-borne viruses among
IDUs. Although HIV is probably the best-known blood-borne infectious agent spread
disease through multi-person use of drug injection equipment, many other pathogens can
be transmitted by this route.

Several factors have been associated with extremely rapid transmission of HIV among
IDUs: (1) lack of awareness of HIV/AIDS as a local threat; (2) restrictions on the
availability and use of new injection equipments and (3) mechanisms for rapid, efficient
mixing within the local IDU population. Without an awareness of AIDS as a local threat,
IDUs are likely to use each other’s equipment very frequently.

Legal restrictions can reduce the availability of sterile injection equipment, and thus lead
to increased multi-person use (“sharing”) of drug injection equipment. In some
jurisdictions, medical prescriptions are required for the purchase of needles and syringes.

47
Possession of needles and syringes can also be criminalized as “drug paraphernalia,”
putting users at risk of arrest if needles and syringes are found in their possession. In
some jurisdictions, drug users have also been prosecuted for possession of drugs based on
the minute quantities of drugs that remain in a needle and syringe after it has been used to
inject drugs. In addition to the possible legal restrictions on the availability of sterile
injection equipment, the actual practices of pharmacists and police can create important
limits. Even if laws permit the sale of needles and syringes without prescriptions,
pharmacists may choose not to sell without prescriptions, or not to sell to anyone who
“looks like a drug user.” Similarly, police may harass drug users found carrying injection
equipment even if there are no laws criminalizing the possession of narcotics
paraphernalia.

Simple “sharing” of needles and syringes among sexual partners or small groups of
friends is not sufficient to cause an “epidemic” of rapid HIV transmission among IDUs.
For rapid transmission to occur there needs to be some mechanism by which large
numbers of IDUs can share equipment with each other within relatively short time period.
Shooting galleries (places where IDUs can rent injection equipment, which is then
returned to gallery owners for rental to other IDUs) and dealers’ work (injection
equipments kept by a drug seller, which can be lent for successive drug purchases) are
examples of situations that provide rapid transmission of HIV among IDUs. In many
cities, IDUs will gather at specific locations, form loose groups to purchase drugs (better
prices usually can be obtained if users purchase in large volumes), and then inject
together, sharing the injection equipment. Membership in these drug purchasing groups
will then change very rapidly. Several studies have indicated that the infectiousness of
HIV is many times greater in the 2 to 3 month period after initial infection compared to
the long “latency” period between initial infection and the development of severe
immune suppression. Thus, the concentration of new infections in these settings may
synergistically interact with continued mixing and lead to highly infectious IDUs
transmitting HIV to large numbers of other drug injectors.

48
Several other factors may also facilitate the sharing of injection equipment. For example,
in some countries, for many people injecting is the only way to begin using drugs and
sometimes drugs are only available in inject able forms. Further, high rates of
polysubstance use may lead to intoxication with alcohol or other drugs prior to injecting,
which increases the likelihood of sharing “dirty works.”

Besides sharing of injecting equipment, HIV is also transmitted and acquired through
unprotected sexual intercourse. Among many people who use recreational drugs, periods
of drug use are likely to be interspersed with phases comprising conventional behavior,
including sexual activity. The risk of sexual transmission of HIV through sex with an
IDU is closely related to the frequency of equipment sharing among drug injectors, to the
frequency of risk-associated sexual activity, and also to the extent of the epidemic in a
given area.

3.9. EDUCATION OF IDUs

One of the interventions that can facilitate risk reduction is education of IDUs to raise
their awareness about the risk of contracting HIV through injection drug use. Studies
conducted in the United States have shown the positive impact of educational programs
targeting IDUs. In contrast, the impact of a lack of basic factual information about
HIV/AIDS can be seen in the very rapid spread of HIV in many areas of Southeast Asia
where little AIDS education occurred prior to the initial, rapid spread of HIV among
IDUs.
Increasing Availability of Clean Injection Equipment Making available clean needles and
syringes has been very controversial in some countries as a way to prevent HIV among
IDUs. Clean needles and syringes can be made available to IDUs through needle and
syringe exchange programs, pharmacy-based programs, or pharmacy sale of needles and
syringes. Secondary outlets, such as health centers, drug dealers, vending machines, and
outreach distribution, could be used as well. Because of legal restrictions in many
countries, it has been very difficult to implement needle exchange programs.

49
Evaluation of needle exchange programs around the world shows that they have played a
significant role in lowering rates of needle-sharing among IDUs, and have served as
referral sources for other health-related services. Needle exchange programs have also
been found not to lead to an increase in drug use nor an increase in HIV drug risk
behaviors. Furthermore, HIV infection rates in many cities have remained at a stable rate
after implementation of needle exchange programs.

4.0. HIV TESTING

The role of HIV testing in prevention is not conclusive. Studies conducted in the United
States and other countries have shown that while testing for HIV may have contributed to
the prevention of HIV/AIDS among the general population, the effect among IDUs was
not conclusive. In order to use testing for prevention purposes, appropriate counseling
must accompany testing. In addition, issues such as anonymity and confidentiality are
also important.

4.1. SOCIAL NETWORK INTERVENTION

During the last few years, network intervention techniques have been used to promote
risk reduction among IDUs. A drug injector is asked to bring in members of his or her
network for a series of group sessions. In the sessions they discuss HIV and how they can
work together to protect themselves from infection. Underlying this is the theory that the
group has norms and bonds within itself. Thus, they will mutually reinforce each other in
their efforts to avoid risk behaviors. The expectation is that the participants in the
networks are more likely to change their risk behaviors than those who receive only
individually focused intervention. Studies conducted in the United States have shown that
participants in the network intervention changed a variety of risk behaviors more than did
drug injectors who received an individually focused intervention.

50
5. Speisser L, Ramon A, Pele G, et al. Prevention advertising campaigns in France: from a product
communication to a communication based on risky situations. International Conference on AIDS 1996,
Vancouver, B.C. Abstract no. Th.C.4518

CHAPTER THREE

3.0. Research Methodology / Research design

This is a Survey research using questionnaire administered to respondents who are

youths. The questionnaires will include both open-ended items and close-ended items.

3.1. Location of the Research

The research will be carried out in Bandung with specific focus on selected students
(male and female) in three universities.

3.2. Sampling data collection techniques

The quantitative techniques will be used for this study in order to provide broader
contextual information on general level of HIV/AIDS awareness , attitudes to the use or
not use of condoms among spouses ,and provide a detailed understanding of the rang of
socio-economic , cultural , educational and other related factors that contribute to the use
or non-use condom .

3.3. Population and Sampling strategy

In order to achieve the research objectives above, the proposed unit of analysis will be the
youth (university) students both boys and girls. In total, two hundred (200) respondents
will be selected from among the categories mentioned above. This will be achieved by
the use of Stratified random sampling, where in the first stage, a total of (4) strata’s of

51
fifty (50) respondents each from the categories mentioned using a purposive sampling
method. Then, within the Subpopulation (Strata), a simple random and or systematic
sampling will be used to get the required data.

3.4. Research instruments

The researcher will use among other the following data collection instruments:

 Self administered Questionnaires based on the research questions;

 Interview schedules and guidelines;

 Observation techniques;

 A Laptop;
 A Voice recorder;

 A Camera;

 Writing aid, e.g. Books, pens, pieces of paper, a ruler, a pencil and Indonesia-English
Dictionary,

3.5. Data collection procedure

The researcher intends to use both Primary and Secondary methodologies for data
collection. A variety of techniques will be used, for example, a survey design with
structured interview schedules, key informant interviews, participant observations, and
group discussions.

3.6. Secondary data Collection

52
Textual data collection will be used in the first stage of the research in order to have
literature in that context. Relevant reports and published literatures related to the topic
will be accessed to get data, for example, (sensitization programs on HIV/AIDs records
of voluntary declaration of HIV/AIDs status by HIV/AIDs. monthly or quarterly reports
by the organisations. Key informant interviews will be contacted to review the secondary
data and information gathered from the concerned agencies and documents.
Primary Data Collection

3.7. 1.Observation

The researcher will use observation technique to assess the attitude of students when
stalking of HIV/AIDs and condom use, attending sensitaisation programmes .Here the
researcher will physically be on the field to see the activities going on there to get an
instant data.

3.5.2. Questionnaires.

This is a survey research where a self administered questionnaire will be issued to the
selected respondents. The questionnaires will neither be posted by mail nor faxed but
delivered by the researcher in person and he will also collect them himself.

The respondents are given freedom and liberty to answer the questions from their own
experience without the influence of the researcher. The researcher is opting for this
method because it helps to capture the non visible aspects of the information needed for
the study.

The content of the questionnaire will include among others the letter grades like: strongly
agree, agree, disagree, and strongly disagree and the level of sharpness among the
population will be considered, hence, Interval level measurement is preferred for the
study.

Interviews

53
3.5.3. Directly administered interview

Interview of respondents will be conducted using structured questions which will be in

line with the study objectives.

Face-to-face interviews will be contacted for data collection. This will involve the
formulation of an interview schedule before going to the field. The questions in the
interview guide will be pre- arranged so that some important issues are not left out. The
researcher will also use some probing questions that might help to capture latest
information.

3.5.4. In depth interviewing

This method will target the HIV/AIDs organisations, students leaders, some selected
sexual workers, drug users, street children and other health centers and the interview
guides will be in an open-ended form questions.

3.5.5. Data Analysis procedure.

The researcher expects to base his analysis of the close-ended items on a scale of 1 to 2 as
illustrated on the table below. Ratio level of measurement shall be used to analyse the
data.
Table 1.1: Scale for Answering Questionnaires from Strongly Agree to strongly disagree

Category Strongly disagree………… ………. Strongly Agree

Level of agreement 1 2 3 4 5 6 7 8 9 10
Scores (S) 5 4 3 2 1 1 2 3 4 5
Samples (n)
Total (S*n)

The data shall be analysed and interpreted in relation to the objectives of the study.
Descriptive analysis will be employed using frequency, percentage, mean, range standard
deviation and rankings to describe the independent and dependent variables.

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3.6. Anticipated problems and possible solutions

It’s anticipated that a number of problems will be experienced especially during interview
for example;

 Some respondents will be difficult to contact as they have to attend lectures during
day.
 Negative responses will be expected to occur frequently from respondents due to fear
of disclosing their HIV/AIDs status.
 Inadequate data by HIV/AIDs students’ organisations in the selected universities.

The following are the solutions for the above mentioned problems;

 To diminish this, permission or letter from university will be used as a measure to

ensure confidence among the respondents .Alternatively, countless of respondents
will be approached in order to compliment the required sample size.
 Also to minimise on negative tendencies confidentiality will be insured to the
respondents by not disclosing their names, names of universities selected and the
streets of sex workers.

3.7. Time- frame

The proposed study will be implemented in six (6) months of 2010-2011 and it will start
in November and end in April 2011.

55
The table below presents the major objectives and the time flame-work for the study.

ACTIVITIES NOV DEC JAN FEB MAR APRIL

literature review
key informative interview
Developing questionnaire
preparation for fieldwork
conducting field work
Data analysis
Publication of the report
3.8. Predicted results and implications
The study will lead to the contributions such as creating awareness, clear
communication for an effective behavior change of agencies working towards
combating HIV/AIDs infection in the country and to make condom use more
acceptable among risky groups such as sex workers, drug users who are the youths.

The findings will important to Indonesia ministry of health to take into account the
behaviors of the youths and will take the findings since at present they are focusing at
100% condom use among commercial sex workers only.

REFERENCES

56
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END

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