Why do female sex workers in Indonesia not use condoms: a mixed methods study of the heterogeneous contexts of condom use

Dewi Ismajani Puradiredja, London School of Economics and Political Science (LSE)
Ernestina E. Coast, London School of Economics and Political Science (LSE)
Rebecca Sear, London School of Economics and Political Science (LSE)

Context-specific knowledge is essential for the design and implementation of more effective HIV/AIDS policy and intervention strategies. This study uses a comparative rural-urban research design and a mixed methods approach to collect and analyse qualitative and quantitative data on the barriers to condom use in the context of transactional sex by female sex workers (FSWs) in Indonesia. Primary data collection includes a structured survey of urban and rural FSWs (n=310) in Indonesia, and in-depth interviews with a sub-sample (n=12). A novel three-staged purposive sampling technique enabled the inclusion of notoriously under-researched sub-populations, such as rural FSWs and FSWs in urban slum areas with high rates of crime and violence. Quantitative data were collected on HIV/STI-related awareness and behaviours, including condom use and a social-cognitive self-efficacy measure; and on respondents’ demographic and socio-economic characteristics. Qualitative data were collected on the type of sex work setting, including work organisation, atmosphere, and social relationships; general and HIV-related risk perceptions and prevention; attitudes towards condoms and their use; and situational accounts of condom use negotiation by FSWs with their clients. Results show that HIV/AIDS and condom awareness are by and of themselves insufficient predictors of condom use in sex work. Instead, variations in sex work setting in combination with respondents’ demographic, socio-economic, psychosocial and personal characteristics create and relate to different inhibitors to condom use with clients. Condom use among FSWs is determined by factors such as type and pricing of sexual services, gender power relations, economic pressure, social marginalisation, harassment-prone work settings, unsupportive sex workplace management, and familiarity with clients.