Prevention of HIV Transmission

in Intimate Partner
Relationships
Saramma Thomas Mathai
Consultant to UNFPA
November 1, 2016
 Outline

Prevalence and trends

HIV in intimate partnerships
UNAIDS ‘Framework for for prevention of HIV
transmission among intimate partners’
Recommendations
Section 1
PREVALENCE AND TRENDS
People living with HIV in Asia and the
Pacific 2013
New HIV infections in Asia and
the Pacific, 2013
 Estimation of number of new
infections in Indonesia 2000-25
100,000

90,000
Increase in MSMs but low risk females largest
80,000 group with new infections

70,000

60,000

50,000

40,000

30,000

20,000

10,000

0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Clients MSW MSM TG FSW Low-risk males Low-risk females IDU

Source: MOH: HIV Mathematical Model

 Aggregate data on HIV
infections by sex 2008-2014
120
More than 40% are women
100

80

55.9 56.7 57.7 58.1

64.7 61.3
65.6
60 M
F

40

20 44.1 43.3 42.3 41.9

35.3 38.7
34.4

0
2008 2009 2010 2011 2012 2013 2014 (till Oct)

UNAIDS Indonesia
 Selected behavioural patterns of
key affected populations
Behaviour IDU MSM Transgender DFSW IDFSW Mobile workers $

HIV prevalence 44.5% * (D) 17.3%* (I) 19%* (D) 10%* (D) 1.6% (D) 0.2% (highest in
trends truck drivers and
sailors)

Syphilis prevalence D* I* D* D* D I (same as above)

trends

Gonorrhoea D* I* D* D* D I (same as above)

prevalence trends

Chlamydia D* I* D* D* D I (same as above)

prevalence trends

Average age >30 <25 >30 >30 >30 >30

Knowledge about >70% (I) >70% (I) >70% (I) >80% (I) >70% (D) >70% (I)
HIV and prevention

Comprehensive 42% (I) 32% (I) 27% (I) 38% (I) 16% (D) 18% (I)
knowledge
(Approx.)

$ Mobile workers include truck drivers, motor taxi drivers, sailors, port workers, factory workers
Source: IBBS 2013 and * Technical report: 2013 Sero-sentinel surveillance and 2013 Rapid behavioural survey
D- Decrease, I - Increase
 Selected behavioural patterns of
key affected populations (contd.)
Behaviour IDU MSM Transgender DFSW IDFSW Mobile workers $

% who bought or 15% 46% - - - 32%

sold sex

Condom use during 44% (I) 74% (I) 70% (I) 77% (I) 50% (D) 43% (I)
the last
commercial sex

Consistent condom 19% (I) 38% (I) 39% (I) 48% (I) 29% (D) 20% (I)
use during
commercial sex

Access to free Limited Limited

condoms

Other risky Average number Average number 66% lived with

behaviours 15% married of clients 2-14 of clients 2-6 wife and children
Casual sex
partners include
transgender and
females

$ Mobile workers include truck drivers, motor taxi drivers, sailors, port workers, factory workers
Source: IBBS 2013 and * Technical report: 2013 Sero-sentinel surveillance and 2013 Rapid behavioural survey
D- Decrease, I - Increase
Population distribution by condom use
during last commercial sex, 2011

DFSW- HRM- High risk men

Source: IBBS 2011
Young people at risk- Negative impact on
demographic window of opportunity

20% of
population
15-24
Knowledge
about HIV
20% among
20-24 years
 Summary
Increasing new HIV infections
Increasing trends among women and new
infections consistently high among low risk
women and probably increasing
Low condom use among high risk men (clients of
sex workers)
Increasing new infections among MSMs
Young people at risk and potential negative
impact on demographic window of opportunity
Section 2
HIV TRANSMISSION IN INTIMATE
PARTNER RELATIONSHIPS
HIV transmission among intimate partners
in Indonesia- key facts
 Intimate partnership refers to marriage
 HIV epidemic powered by men who buy sex, men who inject drugs
and men who have sex with men
 Evidence of transmission expanding to people who buy and sell sex
and wives
 15% IDUs, 46% of MSMs and 32% of mobile men buy sex. 15% of
MSMs are married (most likely their bisexual status is hidden from
their spouses) and 66% of mobile men live with families.
 No data on intimate partners of IDUs or sex workers. Information
on types of partners of MSMs is not known.
 Projected total number of HIV
infections among various groups linked
to IDUs in Jakarta 2000-2020
HIV transmission among intimate partners
in Indonesia- key facts
 The data on HIV among married women is not available
 Less than 1 percent of ANC clients are tested for HIV and it
was found that 3 percent of those tested have been positive.
ANC Surveillance not done except in Papua (because of the
nature of the epidemic)
 HIV prevalence among pregnant women was estimated at
0.38 percent in 2012, and was expected to increase to 0.49
percent in 2016
 In Indonesia, it is estimated that about 4.9 million women are
wives of men who are at risk of HIV infection
 Dynamics of HIV transmission in
intimate partner relationships in
Indonesia
Women who sell Men who GWL (Gay, Injecting
sex 230,000 buy sex - Waria, drug users
6.7 million Lesbian- 1.12 75,000
(2-20% of million
adult men)
Clients
(migrants,
truck drivers, Male
sailors partners

Female partners (wives) of men at high risk 4.9 million

Source:Adapted from UNAIDS: Intimate partner relationships in Asia. Data from MOH: Guidelines for
prevention of sexual transmission 2014
 Intimate Partner Violence -a facilitating factor
on HIV transmission in Marriage
16
Indonesia- Violence against women (VAW) by province from a
14 national survey in 2006

12

10 Abusive men are twice likely to acquire sex outside

marriage and likely to have unprotected sex
8

Source: Violence against women survey presented by Division of Region Resilience Statistics, BPS at the Workshop on Integration
of Gender Perspective into Official Statistics, Japan 2013
A causal model showing linkages among factors that influence HIV
transmission in intimate relationships

Structural
and social Stigma and
factors discrimination Interpersonal
risk factors
Men’s behavior – Multiple
partners, MSM, IDU, etc.

Lack of 4.9 million women who Non- Migration

sexual are partners of men who disclos and
and RH buy sex ure of mobility
services HIV
status

Intimate partner violence Gender

Lack of
and
economic
sociocultur
rights Lack of al norms
sexual
negotiation

Source: Adapted from UNAIDS: HIV transmission in intimate partner relationships.

 Contributory factors
The unmet need for sexual and reproductive
health services of MSMs, IDUs and clients of
sex workers, sexual and reproductive health
needs of migrants and mobile populations,
and changing sexual behaviour of young
people with no change in access to services
are some of the contributory factors to spread
of infection among intimate partners
Section 3
CURRENT POLICIES AND PROGRAMMES IN
RELATION TO INTIMATE PARTNER
TRANSMISSION OF HIV
 Commitments of Government
Indonesia is committed to ICPD Programme of
Action which emphasised integration of SRH
and HIV programmes, gender equality, male
involvement and SRH of young people.
Indonesia is committed to Political
Commitment of 2011 as well as its
commitments to the ASEAN Declaration –
both recognise reducing new infections and
infections among newborns for prevention of
intimate partner transmission is critical.
 Policy and programmatic gaps

 National HIV and AIDS Strategy and Action Plan 2015-

2019 and National Guidelines for Prevention of Sexual
transmission 2014 do not emphasise on prevention of
HIV and STIs in intimate partner relationship.
 The focus on elimination of mother-to-child transmission
is on prongs 3 and 4 (Prong 1 focuses on prevention
among childbearing and prong 2 focuses on unintended
pregnancy among women living with HIV)
 Condom promotion is a key component of interventions
for key affected populations. However, there is no
evidence of promotion of dual protection among sex
workers or among partners of men who buy or sell sex.
 Policy and programmatic gaps
National RH strategy 2004 – (new strategy being
developed) no mention of SRH services for key
populations or on intimate partner transmission
Current FP guidelines do not focus on HIV
prevention among partners through dual
protection
Adolescent sexual and reproductive health
guidelines do not mention dual protection
?Domestic violence policies do not highlight the
increased risk of HIV transmission
Section 4
UNAIDS: FRAMEWORK FOR ADDRESSING HIV
TRANSMISSION IN INTIMATE PARTNER
RELATIONSHIPS
 UNAIDS: Four major recommendations for
addressing HIV transmission in intimate partner
relationships
• HIV prevention interventions must be scaled up for
MSMs, IDUs and clients of FSWs and should emphasize
the importance of protecting their regular female
partners
• Structural interventions should be initiated to identify
and address the needs of vulnerable women and their
male sexual partners
• HIV prevention interventions among mobile
populations and migrants must be scaled-up and
include components to protect intimate partners
• Priority should be given to operations research to
develop better understanding of the dynamics of HIV
transmission in intimate partner relationships.
Source: UNAIDS: HIV transmission in intimate partnership relations in Asia, 2009
Strengthening HIV prevention interventions for MSMs,
Injecting drug users and clients and emphasize
protecting their regular female partners
Ensure provision of SRH services for MSMs, IDUs
and FSWs and their IPs
Address the issues of masculinity and gendered
identifies for men
Build partnerships with local private health
practitioners to address the needs of men who
have sex with men, injecting drug users, clients of
female sex workers and their IPs
Engage people living with HIV to meet their SRH
and treatment needs.
Source: UNAIDS: HIV transmission in intimate partnership relations in Asia, 2009
Initiate structural interventions to identify and address
the needs of vulnerable women and their male sexual
partners
• Engender SRH and HIV programmes through initiating
inter-ministerial and inter-departmental coordination of
gender-specific initiative into SRH and HIV programmes
• Widen the scope of RH strategies to include services for
male sexual health
• Integrate treatment programmes for AIDS- related
illnesses and programmes addressing mother to child
transmission into health systems, in order to ensure
sustainability and lowering of transaction costs for
service provision
• Promote condom use as dual protection for both HIV and
STIs and unplanned pregnancies
• Train providers of SRH services in the importance of
intimate partner transmission of HIV and STI and
importance of dual protection Source: UNAIDS: HIV transmission in intimate
partnership relations in Asia, 2009
Initiate structural interventions to identify and address
the needs of vulnerable women and their male sexual
partners (Contd)
• Encourage governments to take responsibility for the
provision of Life skills education and SRH/HIV counselling
for young people through relevant sectoral programmes
• Develop indicators and mechanisms for monitoring
gender sensitiveness of SRH and HIV services
• Address male behaviour and issues of masculinity in
programmes for men especially around intimate partner
violence including sexual violence
• Reduce stigma and discrimination to promote voluntary
HIV testing and disclosure among couples

Source: UNAIDS: HIV transmission in intimate partnership relations in Asia, 2009

Strengthen HIV prevention interventions among mobile
populations and migrants and include components to
protect intimate partners
• Dialogue among key ministries within countries (eg. Health,
interior, justice, labour, social welfare and education)
between different provinces and should be encouraged in
order to provide and consistent access to HIV prevention,
treatment, care and support.
• Accurate information on the impact of migration on HIV IPT
should be gathers by methods that protect human rights,
build trust and no harm
• Pre and post departure should include components on the
prevention of HIV transmission to IPs
• Orientation on HIV transmission to intimate partners
should be organized for key stake holders , such as
immigration officials, social welfare policy-makers and
health service providers.
Source: UNAIDS: HIV transmission in intimate partnership relations in Asia, 2009
 Priority should be given to operations research to develop
better understanding of the dynamics of HIV transmission in
intimate partner relationships

• Magnitude of sero-discordance in the country

• Linkages between risk behaviours of MSMs, IDUs,
clients of sex workers and their intimate partners
• The extent to which HIV is transmitted from migrant
men to their IPs between destinations and source
areas and from rural to urban areas
• The challenge of interventions targeted to me who
have sex with men, injecting drug users and clients of
sex workers in promoting partner notification and the
prevention of HIV transmission in intimate sexual
partner relationships

Source: UNAIDS: HIV transmission in intimate partnership relations in Asia, 2009

Section 5

RECOMMENDATIONS
 Policy and strategies

 The current policies on HIV/AIDS including STIs prevention

(PMTS) should be reviewed and strategies for prevention of
intimate transmission should be incorporated, as relevant
 Within the overall policy and strategies for HIV/AIDS and STI
prevention, a framework on prevention of HIV and STI
transmission among intimate partnerships, that emphasizes
condoms for dual protection should be developed (UNAIDS
framework could be the basis)
 Gathering evidence for developing the
strategy on prevention of intimate
partner transmission
Existing data on HIV prevalence should be analyzed
to get data on prevalence among married women
Who is an intimate partner should be defined
(UNAIDS list from regional studies in next slide)
Undertake epidemiological studies to understand the
dynamics of transmission among intimate partners
Assess the STI and testing and counselling and
treatment centres to determine the current practices
with regard to partner treatment and follow up
Potential list of intimate sexual partners
at risk of HIV (from regional studies)
 Women in sero-discordant relationships
 Women with partners who inject drugs
 Women with MSM partners
 Transgender population
 Women reporting anal sex
 Female survivors of sexual and physical violence
 Women with male partners who regularly drink large quantities of
alcohol
 Female partners of mobile and migrant workers
 FSW with intimate male sexual partners
 Women in closed settings (prisons, rehabilitation centers, domestic
servants, etc.)
 Women diagnosed with TB
 Trafficked women

Source: UNAIDS Guidance Note on identifying opportunities for addressing Intimate Partner Transmission of HIV in
GFATM Proposals and National Strategic AIDS Plans
 Gathering evidence for developing the
strategy on prevention of intimate partner
transmission
Assess the current SRH services for MSMs,
IDUs and FSWs
Map the availability and accessibility and
barriers to accessing services (should cover
public and private sector facilities)
Assess the coverage, quality, effectiveness and
whether there is adequate focus on
prevention among their intimate partners and
emphasis on dual protection
 Promotion of dual protection is critical
for preventing intimate partner
transmission
Dual protection means the simultaneous
prevention of unintended pregnancy and HIV and
STIs infection through the consistent and correct
use of male or female condoms, alone or in
combination with another contraceptive method.
A woman and man of reproductive age group
need dual protection if they are having sexual
intercourse and want to avoid a pregnancy or
protection from STIs or HIV if one of them had
unprotected intercourse with another partner of
the same sex or opposite sex
Major recommendations for promotion of
dual protection policy and programmes
Current HIV/AIDS and STI policies including
policies on prevention of mother to child
transmission should incorporate dual protection
using condoms.
Family planning services should ensure
information about dual protection. Risk
assessment of clients for HIV and STI should be
part of counselling and screening for medical
eligibility. Training of providers is critical.
Programme interventions for young peoples
should focus on dual protection