The Behavior of Using Condom by MSM or Men Who Have Sex with

Men in Sukoharjo

Yutti Anggelia

, Tanjung Anitasari Indah Kusumaningrum

Public Health Department, Universitas Muhammadiyah Surakarta

Keywords: Behavior, condom use, Man Who Have Sex with Men.

Abstract: The amount of MSM who suffer from HIV in Sukoharjo Regency reached 30.95% in 2017. HIV prevention

in MSM was attempted by consistent use of condoms every time they have sexual intercourse. The purpose

of this research is to describe MSM’s behavior of using condoms based on Health Belief Model in

Sukoharjo. The research belongs to qualitative type with a case study approach. Informants of this research

were five MSMs as the main informant, as well as one peer educator and one field coordinator as

triangulation informants. The data were collected through in-depth interviews and then they were analyzed

through content analysis. The results showed that most MSMs realized that they were susceptible to HIV

and had the perception that condoms are beneficial to prevent HIV transmission. However, only two MSMs

consistently use condoms. Most MSMs did not use condoms consistently because they were not sure of the

effect and they found it to cause discomfort. They felt uncomfortable when the sex partner was using

condom, yet they felt safe when having sex with a regular partner. Therefore, the barriers and self efficacy

of the MSMs are related to the success of using condoms consistently. Hence, it is necessary to educate

MSMs and their regular partner on using condom.

1 INTRODUCTION

HIV/AIDS is a public health problem that requires

serious attention. HIV / AIDS continue to grow and

become the global problem. The prevalence of HIV /

AIDS worldwide continues to increase. The United

Nations Program on HIV / AIDS (UNAIDS) Global

AIDS Update (2016) stated that the prevalence of

HIV / AIDS in the world reaches 36,7 million

sufferers. In 2013 there were 12,9 million sufferers

of HIV / AIDS, 15 million in 2014, and 17 million in

2015. Most of them are from the eastern and

southern Africa region, with 19 million sufferers,

while in Asia the number reached 5.1 million. Asia

is estimated to have the highest rate of HIV infection

in the world. According to WHO and UNAIDS

reports (2016), three countries with the highest rates

of HIV infection included China, India, and

Indonesia.

The number of HIV infections reported in

Indonesia from January to March 2016 was 7.146

people. The highest risk factor for HIV / AIDS

included risky sex in heterosexuals (47%), MSM

(Men Who Have Sex with Men) (25%), others

(25%) and the use of unsterile needles in IDUs (3%),

while the number of AIDS reported on the first

quarter of 2016 were 305. The highest percentage of

AIDS risk factors were risky sex in heterosexuals

(73,8%), MSM (10,5%), use of unsterile needles in

IDU (5,2%), and perinatal (2,6%) (Ministry of

Health of the Republic of Indonesia, 2016).

In 2015, HIV / AIDS cases in Central Java were

ranked 5th in Indonesia, with 747 new cases of HIV

and 637 new cases of AIDS spread in 35

districts/cities. The number of HIV / AIDS sufferers

in MSM in Central Java is 3,4%, but in 2016 Central

Anggelia, Y. and Kusumaningrum, T.

The Behavior of Using Condom by MSM or Men Who Have Sex with Men in Sukoharjo.

DOI: 10.5220/0008371600330039

In Proceedings of the 1st International Conference on Social Determinants of Health (ICSDH 2018), pages 33-39

ISBN: 978-989-758-362-9

Java was in fourth place in Indonesia with the

number of new HIV cases, as many as 4.032,

following East Java with 6.513 cases, DKI Jakarta

with 6.019 cases and West Java with 5.466 cases

(Ministry of Health of the Republic of Indonesia,

2016).

Based on the data of Sukoharjo District Health

Office in Sukoharjo District Health Profile there was

an increase in new HIV cases, that was from 27

cases in 2014 to 62 cases in 2015. According to the

Sukoharjo AIDS Commission (2017) 84 cases of

new HIV positive were found from January to

October 2017, with the highest risk factor percentage

in MSM (30,95%), Heterosexual (9,52%), HRM

(9,52%), TB (8,33%), Pair of PLWHA (4,76%),

Pregnant women (3,57%) STI (2,38%), IDU

(1,19%), transgender (1,19%) and others amounted

to (28,57%). The high number of HIV / AIDS cases

in MSM groups requires prevention efforts. One

effective prevention measure is the consistent use of

condoms (National AIDS Commission, 2015). The

results of a study by Firdaus (2013) showed that the

frequency of condom use in the case groups (HIV-

infected MSM) was lower (41,3%) than in the

control group (HIV non-infected MSM) (58,6%).

There is significant relation between condom use

behavior in risk groups and the incidence of HIV. In

line with the research, Nirmala (2016) stated that

MSM couples never use condoms during sexual

intercourse. This is because these MSM couples feel

healthy, even though their health is not fully

guaranteed.

In general, MSM belong to a population that

sells sex. MSM also do sex buying behavior. Sex

selling behavior of MSM in 2011 based on

Integrated Biological Behavior was 49%, and sex

buying behavior in MSM was 19%. The data

showed that the percentage of sex selling was higher

than sex buying of MSM. The same thing was also

indicated by other research showing that MSM tend

to sell sex to male. MSMs doing sex selling can

cause couple at risk of HIV. MSM who have anal

sex was highly at risk of HIV because it tends to

injure the anus (Firdaus & Agustin, 2013). Based on

the data from the Ministry of Health of the Republic

of Indonesia (2011), it was revealed that within the

population, MSMs is the group who perform sexual

intercourse even if they were not paid (84%).

However, the consistency of condom use by MSM

in the last commercial sex was only 61%. MSM was

also included in the population with the lowest

percentage of condom use in, namely sex with an

irregular sex partner and without paying/paid (54%).

Ministry of Health of the Republic of Indonesia

(2011) also stated that as many as 31% of MSM had

experienced one of the symptoms of STIs in the past

year and HIV prevalence in MSM was 8%. Using

condom is one of HIV / AIDS prevention measures.

Based on the Health Belief Model (HBM) theory, a

person will take precautionary measures influenced

directly by the results of a belief or health

assessment, namely the perceived threat of illness or

injury, advantages and disadvantages, and

behavioral instructions (Maryam, 2015). There was a

relation between perceptions of vulnerability,

barriers as well as initiator of actions and the

practice of using condom by male sex workers.

Meanwhile, there was no relation between

perceptions of seriousness as well as benefits and the

practice of using condom by male sex workers

(Mukhsinin, 2016).

The practice of using condom by MSMs in

Sukoharjo is supported by the SPEKHAM data on

condom distribution to MSMs (2017), which were as

many as 7.120 pieces in June and 7.765 in

December, respectively. In 2015 the distribution of

condoms to MSMs per June was 7.770. In 2016 in

the same month were 1.224 pieces and as of

December were 2.715 pieces (SPEKHAM, 2017).

Based on a preliminary survey conducted on January

24, 2017, 4 MSMs did not use condoms consistently.

Inconsistent use of condom results from several

things, one of them is forgetting to bring a condom.

MSM also feels that condoms make them

uncomfortable when used during sexual intercourse.

Therefore, it is necessary to study more deeply how

HBM-based of MSMs’ perceptions make them use

condoms consistently or inconsistently.

Based on preliminary survey data from the

Sukoharjo Health Office in the field of P2P (Disease

Prevention and Control), knowledge of MSMs about

the use of condom is still lacking. Many MSMs do

not use condoms consistently when having sexual

intercourse, even though some of them know that it

functions to prevent the transmission of HIV/AIDS

to HIV/AIDS risk group. Hence, the researchers are

interested in examining the behavior of MSMs in

using condom in Sukoharjo according to the Health

Belief Model theory.

2 SUBJECTS AND METHODS

The research belongs to qualitative type that

produces descriptive data in the form of written and

oral words obtained through the process of

ICSDH 2018 - International Conference on Social Determinants of Health

observing human behavior and the environment.

This study used a case study approach in which the

case is the behavior of using condom by MSMs

(Men Who Have Sex with Men) in Sukoharjo.

Taken using purposive sampling, the subjects of this

study consisted of 5 main informants (MSM), who

were either consistent or inconsistent in using

condoms. Triangulation informants in this study

were 1 Peer Educator and 1 field Coordinator. The

data were analyzed using content analysis.

All key informants in this study ranged between

23-47 years of age from several levels of education:

2 people graduated from high school, 2 people

graduated from Diploma-III of Accounting

Management, and 1 person graduated from

Undergraduate degree of Law. All of them work in

private sector. Meanwhile, all triangulation

informants are male and have an age range of 34-39

years old. In terms of education, one informant

graduated from a master’s degree and another was

from vocational school. They are social worker

(Field Coordinator) and Private Employee (Peer

Educator).

3 RESULTS

3.1 Perception of Vulnerability

In the aspect of knowledge about HIV/AIDS, all key

informants and triangulation informants understand

that HIV/AIDS is a disease caused by a virus that

attacks the human immune system. HIV is a virus

while AIDS is a disease. All informants also added

that HIV / AIDS is a deadly disease if people do not

know how to prevent and overcome it. "HIV / AIDS

is an infection of a disease caused by a virus, which

the virus attacks the human immune system, between

HIV and AIDS is different that needs to be

underlined here. HIV is the virus while AIDS is the

syndrome, a group of diseases that attack the human

body."(MSM 5)

All key informants can also explain the way

HIV/AIDS is transmitted: HIV/AIDS can be

transmitted through parenteral (blood transfusion),

sexual, perinatal (pregnancy, childbirth,

breastfeeding), and open wounds contaminated with

blood containing the HIV virus. This is in

accordance with what was conveyed by triangulation

informants (IT1, IT2) that HIV/AIDS transmission

"Through sex, breast milk, syringes, syringes like

drugs, syringe turns" (MSM 2)

MSM's views on HIV/AIDS and modes of

transmission were consistent with the perception of

MSM vulnerability to HIV/AIDS, where most of the

main informants explained that they were very

vulnerable to HIV/AIDS. They felt vulnerable

because of frequent change of partners and

unprotected sexual behavior. However, one MSM

feels that he was not susceptible to HIV/AIDS

because he has a permanent partner and never has

sexual intercourse with any other. "What is certain is

that for the community at risk and have more than

one partner, basically people who have had sex or

have been sexually active are all at risk of

HIV/AIDS. So everyone who has been sexually

active is vulnerable to HIV/AIDS. "(MSM 3) "I have

a regular partner, I don't change partners, so I feel

not vulnerable" (MSM 2)

The MSMs also stated that those who are

susceptible to HIV/AIDS are people who frequently

change sex partners and have anal sex without using

condoms. Yet, other key informants (MSM 3 and

MSM 5) argued that people who are vulnerable to

HIV/AIDS are all people who have had sex. People

who have had sexual intercourse are prone to

HIV/AIDS. Indeed, housewives are also vulnerable

because they do not know what their husbands are

doing when they are outside "One yourself, two

customers, if I think so. We will deal directly. If the

syringe is mostly changing partners, if that is every

day through sex. "(MSM 1) "You could say that all

vulnerable people, there are no people who are not

vulnerable and there are no people who are not at

risk, and not only from the key population,

housewives are also very vulnerable because

housewives do not know what their husbands are

like, children in the womb is actually also

vulnerable, so all those people are vulnerable to

contracting HIV, not just the key population. "(MSM

3.2 Perception of Seriousness

Based on the research, most of the main informants

have a perception that HIV/AIDS is not a severe

disease because when HIV/AIDS is detected, it can

be treated with ARVs. "Not really because if it is

known that HIV can be treated with drugs called

ARV" (MSM 2)

All key informants have different opinions about

the impact of HIV/AIDS; one of which is physical

impact. The main informants (MSM 4, MSM 5)

explained that the impact of HIV/AIDS is the

decrease of immune system due to virus attack to the

human body. Different from this opinion, the main

The Behavior of Using Condom by MSM or Men Who Have Sex with Men in Sukoharjo

informant 3 (MSM 3) stated that HIV can have an

impact on an individual’s psychology. The

psychological impact can cause stress and

depression. In addition, MSM 1 and 2 also argued

that HIV can have a social impact, in that they may

feel discriminated from the environment, such as

being ostracized. HIV sufferers can also die if the

disease is not addressed. "The impact of health is if

HIV attacks antibodies, when a person's antibodies

are weak he does not take ARV therapy, he will be

susceptible to diseases, a mild disease will kill if

they are not immediately on ARV therapy" (MSM 5).

"If the psychic person has been convicted, he will

experience various effects such as stress,

depression." (MSM 3)

3.3 Perception of Benefits

Most of the main informants explained that condoms

are very useful, which is to prevent the transmission

of HIV/AIDS, provided that the method is correct.

Unlike the opinion of other key informants, MSM 5

explained that condoms were not only to prevent

transmission of HIV/AIDS but could also be used as

contraceptives. "It is very useful, because condoms

can function a lot for contraception and can also

prevent HIV transmission as well." (MSM 5)

3.4 Perception of Barriers

All the main informants and triangulation informants

explained that the barrier in using condoms was the

presence of discomfort and unpleasant feeling

(similar to when someone was blocking their way).

Besides, they feel embarrassed about buying

condoms. These barriers resulted in the MSMs’

reluctant use condoms consistently. Even so, the

MSMs tried to reduce the barriers by building

awareness of their partners about the risk of HIV,

using lubricants, as well as negotiating with their

partners to use condom. "There are so many barriers

even though now condoms are given free of charge

but many communities think that using condoms is

uncomfortable." (MSM 3)

3.5 Self Efficacy

Most of the main informants explained that

consistent use of condom was actually good, yet

they were inconsistent in using it. They believed that

it can prevent the spread of HIV/AIDS. It is in

contrast to the opinion of MSM 1 and triangulation

informants (IT1, IT2). The former explained that the

MSMs did not consistently use condoms because

sometimes their partners did not want to and were

uncomfortable using it. Similar argument was also

expressed by the triangulation informants (IT1, IT2),

that the MSMs cannot be 100% consistent in using

condom for the aforementioned reasons. However,

most of the main informants explained that they

managed to use condoms consistently because they

were aware of the high risk of contracting

HIV/AIDS. "Sometimes I don't consistently know

why the customers don't want to use condoms, but

it's good if they are consistent." (MSM 1). "Able.

Because you already know the risk of not using a

condom (MSM 2)

3.6 Cues to Action

All the main informants explained that they had seen

people around them affected by STIs, which were

their own friends, and there was even one of the

main informants affected by STIs such as syphilis,

bacterial fungi. All the main informants also

explained that by looking at the incident of people

around them with STI disease, it would affect the

use of condoms consistently but it all depends on the

spouse and customers. There were also those who

explained that the incidence of STIs in the

surrounding environment was very influential

because he was HIV positive, so he had to be

consistent in using condoms. "I also saw it directly,

it was a friend of mine who had an STI, the pus went

out and the urine was very hot" (MSM 1). "Very,

very influential, yes, yes, because I already knew

that I was positive so I always had to use condoms

consistently. (MSM 3)

3.7 Condom Use Behavior

The main informant explained that he consistently

used condoms because he knows the high risk of

contracting HIV/AIDS. "Always consistent because

of high risk, so always use condoms, and often

mutually mate" (MSM 2)

However, other key informants argued that they

are not consistent in using condom because

sometimes their partners do not want to use it, do not

feel comfortable. "Can't be consistent because the

partner doesn't want to use condoms" (MSM 1)

ICSDH 2018 - International Conference on Social Determinants of Health

4 DISCUSSION

4.1 Perception of Vulnerability

Perception of vulnerability is the belief that illness is

the result of exhibiting certain behavior. Most

MSMs and triangulation informants have known that

HIV/AIDS is a disease caused by a virus that attacks

human immune system. In addition, the MSMs also

explained that those who are susceptible to

HIV/AIDS are those who often change partners

without using condoms during sexual intercourse.

Informants further explained how HIV/AIDS is

transmitted; those are through sexual intercourse,

needles, blood transfusions, breast milk, and HIV-

positive mothers to their children.

The respondents believed that MSMs are

susceptible to contracting HIV because of having

multiple partners, anal sex, and oral sex which

increase the risk of HIV transmission. Based on the

sexual activities, which are mostly anal sex, it does

not rule out the possibility of MSMs being infected

with various types of venereal diseases. Besides

being prone to contracting venereal disease, MSMs

and their partners are also susceptible to other

diseases when the penis penetrates into the anus, it

reaches the sigmoideum colon. The part contains

many bacteria that can infect the penis through anal

sex. In addition, MSMs are also prone to throat

cancer due to oral sex (Kristina, 2008).

4.2 Perception of Seriousness

Perception of seriousness refers to subjective

beliefs that diseases spread as the results of bad

behavior or that people should avoid bad behavior to

prevent them from getting diseases. In this

perception of seriousness, most MSMs argued that

HIV/AIDS is not a serious disease because when

HIV is detected, it can be immediately addressed

with ARVs. However, other MSMs claimed that

HIV may have some effects, such as physical impact

(reducing the immune system and blackening the

skin), mental impact (stress, depression), and social

impact (environmental discrimination, exclusion,

death).

The perception agrees with Mudjahid (2000),

stating that many changes occur within individuals

after being infected with HIV/AIDS. The diseases

they suffer affect personal, social, learning, career,

and family life. Changes that occur inside and

outside of people living with HIV/AIDS (PLWHA)

make them have negative perceptions about

themselves and influence the development of their

own concepts. Some of the problems experienced by

PLWHA, both physically and psychologically,

include: stress, weight loss, anxiety, skin disorders,

frustration, confusion, memory loss, decreased work

enthusiasm, feelings of fear, feelings of guilt,

rejection, depression and even the tendency to

commit suicide. However, the impacts can be

overcome through several ways, such as

approaching MSMs in order to persuade them to

come to services for VCT testing, inviting regular

treatment in HIV/AIDS services, and always

providing education to HIV positive people

continuously so that they can build awareness to

maintain safe sexual behavior.

Triangulation informants revealed that education

is necessary for MSM and PLWHAs, considering

MSMs who see HIV/AIDS to be a very severe

disease are those living in remote areas that have not

been exposed to any information about HIV/AIDS

prevention. Conversely, MSMs in urban areas have

received information about HIV/AIDS prevention,

particularly from the AIDS Commission (KPA) and

NGOs that deal with HIV/AIDS. As a result, MSMs

in these areas think that HIV/AIDS is a non-severe

disease. KPA and NGOs establish a program to

educate the MSMs, that is peer education (PE). PE is

a program in which information and education are

spread and carried out by peer groups. It is seen as a

very effective method in the context of KIE

(Communication, Information and Education)

related to HIV / AIDS.

4.3 Perception of Benefits

Perception of benefits refers to a belief in the

benefits of the recommended method to reduce the

risk of a disease. Individuals being aware of the

benefits of early detection of any disease will

continue to conduct healthy behaviors, such as

taking routine medical check-ups. MSMs have a

perception that condoms are very useful. They also

explained that condoms are one of the media that

can help prevent transmission of HIV/AIDS and for

contraception. However, only two of all MSMs were

always consistent in using condoms, while the other

three were not. It was due to the fear of losing

customers and one of them had a regular partner and

therefore felt safe not to use condoms.

Based on the theory of Health Belief Model

(HBM), people will take preventive measures

directly after they were influenced by the results of a

belief or health assessment, the benefits of

preventive actions other than perceptions of

vulnerability, seriousness, barrier, self-confidence,

The Behavior of Using Condom by MSM or Men Who Have Sex with Men in Sukoharjo

and cues to action (Maryam, 2015). The key

informants believed that the prevention measure for

HIV/AIDS can be done by consistent use of

condoms, by not exhibiting free sex, and by not

changing sexual partner.

4.4 Perception of Barrier

Perceptions of barrier are the beliefs about the value

of the behavior being carried out. It means the

perception of decreasing comfort when leaving

unhealthy behavior. The informants explained that

they experienced a number of barriers while

attempting to be consistent in the use of condoms, in

that the partner or customer does not want to use

condoms, for it creates discomfort and blockage.

Barriers of using condom can be overcome by

multiplying lubricants during sexual intercourse,

particularly to deal with the feeling of being

blocked. Another alternative is to buy condoms with

different flavors for better taste compared to those

provided by KPAs and NGOs. In addition, in

dealing with unwilling partner of the use condom,

MSMs can create an intimate atmosphere with them

while building their awareness of the high risk of

contracting HIV/AIDS if they are not wearing

condom.

4.5 Self Efficacy

As previously mentioned, some MSMs believed that

condom is good to prevent the spread of HIV/AIDS,

yet some others do not want to use it because of their

partner refuses, apart from their awareness of its

usefulness. The results are in accordance with

Green's (1980) theory that knowledge would

influence actions. The availability of condoms that

meet the desire of MSMs (reinforcing factor) is

closely related to the use of condoms by MSMs.

Green (1980) stated that someone's behavior

related to health, in this case is the use of condom, is

influenced by knowledge (predisposing factor). It is

also supported by Notoatmodjo (2003) that

knowledge is a cognitive domain that is very

important for the formation of one's actions. If the

acceptance of new behavior or adoption of behavior

is based on knowledge, then what is learned among

others is that the behavior will be direct. Conversely,

if the behavior is not based on knowledge, the

behavior will not last long. This means that if the

respondent's knowledge is better about HIV/AIDS, it

influences the actions to always use condoms during

sexual intercourse (Notoatmodjo, 2003).

Consistent use of condoms can be increased if

the users are confident. This is in line with the

opinion of the MSMs, stating that the confidence

may appear after they are educated by the NGOs or

AIDS Commission about the benefits of using

condoms during sexual intercourse.

Most MSMs also explained that they could

negotiate the use of condom with their partner

because it has been provided at the stalls. Those who

were aware of the risk tend to be consistent. Three

MSMs believe that they were at high risk, while the

other two were not sure of using condom for fear of

losing customers. This is in line with Schultz's

research in McDonough (2012) that self-efficacy is

significantly associated with safe sexual behavior

such as using condoms, abstinence behavior, and

negotiation to use condoms.

4.6 Cues To Action

A signal to act in general is a person's confidence in

carrying out a particular task, a person's trust in his

ability to persuade in a situation or feel confident

with the healthy behavior being exhibited. MSMs in

this study had a perception about the signal to act by

looking at the incidence of STIs experienced by their

own friends. There is one MSM who is infected with

STIs such as syphilis, bacterial fungi, and lime

infestation. In fact, some who are infected with STIs

do not recover because they are not familiar with

STI services. The incident has encouraged the

informants to use condoms consistently.

MSMs obtained the information about the

usefulness of condom and about HIV/AIDS from

their NGO friends. They were encouraged to use

condom to avoid the disease. Even so, some MSMs

did not use it and continue to have sexu without

using it.

According to the HBM theory, a person will

receive a signal to act. This is a trigger that makes

the person feel the need to take action. According to

Ronsenstock (1982), in carrying out health actions

there is a precipitating factor for deciding to accept

or reject these alternative actions, and the trigger

factor for MSMs in this study are friends who suffer

from STIs or their own experience in suffering from

STIs.

4.7 Condom Use Behavior

In this study, sexual activities that were often carried

out by MSMs include oral and anal sex, “es gosrok”

(rubbing the penis), kissing, rimming (licking the

anus), and pinching the thigh (clipping the penis).

ICSDH 2018 - International Conference on Social Determinants of Health

The activities taken depend on the request of each

partner. Based on their sexual activity, there are

MSM who are associated with regular partners, non-

permanent partners, and once partners. Some

couples use condoms consistently and some other do

not.

Three MSMs use condom consistently because

they successfully negotiate with their partner to use

it. Meanwhile, other MSMs did not do the same

because they feel safe (not contracting the disease)

for having only one regular partner. The former

MSMs were influenced by the perception of

vulnerability, in that they use condom because they

have unsafe sexual behavior, have changing

partners, and choose anal or oral sex; all of which

increase the risk of HIV/AIDS transmission.

Conversely, the latter choose not to use condom

because they were affected by the perception of

barriers, in that their partner is unwilling to wear it.

This is consistent with Kawangung (2012) who

stated one of the reasons of not using condom is

their mutual trust in their partner. Another study

conducted by Jie et al, (2012) revealed that personal

assumptions and feelings towards regular partners

and financial incentives are factors that create the

barriers to use condom by sex workers. Factors of

trust and feelings of love are also barriers that hinder

the use of condoms. It is proven by Stoebenau et al

(2009) in his research about transvestites and that

MSMs have different treatment between clients or

regular customers and a regular partner. Again, an

MSM in this study insisted on not using condoms for

fear of losing customers even though he already

knew how to use condoms: looking at the expiration

date, paying attention to how to open it, sliding to

the edge and then opening, making sure the air

cavity should not bubble up.

5 CONCLUSIONS

Three MSMs decided to use condom consistently,

one MSM did not use it because he has a regular

partner, leading him to feel safer, and another MSM

did not use condom for fear of losing his customers.

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