Date Published: April 8, 2019
Publisher: Public Library of Science
Author(s): Luh Putu Lila Wulandari, Abby Ruddick, Rebecca Guy, John Kaldor, Shira M. Goldenberg.
In many Asian countries, men who purchase sex account for the largest single network of people which often face elevated HIV risk in relation to the general population. However, high proportions of these men have never undertaken HIV testing. We assessed barriers to and facilitators of HIV testing among men who purchase sex in Indonesia, including the acceptability of HIV self-testing. A qualitative study was conducted during December 2016-January 2017 at fourteen sex-work venues and one voluntary HIV counselling and testing (VCT) clinic in Bali. Interviews were conducted with men who purchase sex exploring the men’s views on HIV testing. Data were examined using thematic analysis. Twenty-nine men participated in the study. The themes that emerged regarding the barriers to HIV testing included fear of potential shame, embarrassment, and confidentiality breach in accessing HIV testing; fear of social exclusion if the test result was positive; self-treatment and prevention; the distance to a clinic; time constraints; and fear of an invasive testing method. Factors that were seen as facilitating a test were the convenience of time and place; the provision of speedy results; and privacy. Participants expressed interest in HIV self-testing and preferred it to clinic-based testing due to the privacy and confidentiality of the results. The findings support the introduction of an HIV self-testing strategy among this group to improve access to HIV testing.
Between 8% and 35% of new reported HIV cases in almost all regions globally in 2017 were estimated to occur among men who purchase sex and sexual partners of high-risk groups , In many Asian countries, men who purchase sex represent the largest single network of people which often face elevated HIV risk in relation to the general population . With a total population of men in Asia at more than 2.3 billion , estimates have ranged from 0.5% to 15% of the adult male population as having purchased sex  from female sex workers, among whom HIV prevalence was estimated at 5.2% in Asia in 2012 .
The COREQ qualitative reporting guidelines  were used to guide the development of this report, with the information presented in accordance with the COREQ checklist. COREQ is a formal guideline aimed to improve the transparency of reporting of the data collection and analysis method used in qualitative studies. It contains a checklist of research team reflexivity, study design, and analysis and findings .
About 50 men were approached, of whom 42% refused to participate. The majority of those who refused to take part were men who purchase sex from non brothel-based venues; and they expressed lack of time and concern about confidentiality as their main reasons for refusal. All those who agreed to participate in the study provided socio demographic characteristics before the interview. Of the 29 men interviewed, 24 were clients of brothel-based female sex workers. Sixteen were Balinese, and the rest Javanese. Four men had previously been involved as workers in brothels, but were no longer at the time of the interview. Only nine (31%) had undertaken HIV testing and of those, only four (13.8%) had undertaken HIV testing in the last year (Table 1).
Stigma towards people living with HIV within health care facilities is significant in Indonesia [61–63], and engaging in commercial sex is viewed as socially unacceptable. Although participants acknowledged that HIV testing is important for knowing one’s HIV status, they were concerned about the social implications in accessing HIV testing at the clinic and receiving a positive result, and preferred a more confidential method of testing. Similar findings have emerged from studies among men who purchase sex in Guatemala  and South Africa , where confidentiality concerns hindered participants from having an HIV test, and in Tanzania, where confidentiality was a key factor in determining the choice of HIV testing strategy .
This study has revealed important perceptions related to structural and individual barriers to HIV self-testing in Bali. Men indicated that if they could choose, they would prefer a test that is confidential, so that only they would know the result. Men also expressed their interest in HIV self-testing, indicating the need for further research on the acceptability and feasibility of HIV self-testing among men who purchase sex. Future HIV programs should also continue to explicitly address misconceptions about HIV risk and disease progression, and to more vigorously emphasise the availability of treatment for HIV as a chronic condition.