The Sexual Behavior of Male Sexual Partner of Tranvestite in the Prevention Efforts of HIV/AIDS Transmission

Transvestite is one of the high risk groups in HIV/AIDS. Integrated Biological and Behavioral Surveillance (IBBS) states that in 2011, the HIV prevalence among waria in Indonesia has reached 22%, increasing from 2009 (18.96%). Such occurrence is because transvestite usually has multiple partners in intercourse both oral and anal sex, and rarely use condoms. Similarly, the male regular partners of transvestite also have sex with multiple sexual partners. Therefore, they also have a high risk of spread of HIV/AIDS. The objective of this study is to analyze sexual behavior of male regular partner of transvestite in Efforts to prevent the spread of HIV/AIDS. The study was carried out in 2014 using qualitative approach. Data was collected by in-depth interview on 6 male regular partner of transvestite through purposive sampling and triangulation informants of peer educators. The result shows that the use of condom on male regular partners of transvestite is still low and they inconsistently use when having sex with transvestite, female sex workers and female girlfriend. Their knowledge about HIV/AIDS is not good, and some regular partner of transvestite also felt susceptibility to contracting HIV. However, the perceived severity and perceived of benefits male regular partner of transvestite is good about HIV /AIDS despite the barrier of perceived and perceived self-efficacy is low related access to condoms.

from the data of Semarang City Health Office, the cumulative number of HIV/AIDS in Semarang since it was first discovered in 1993 until 31 March 2012, there are as many as 232 cases of AIDS and 705 HIV cases. This number places Semarang as the first rank of city with the highest HIV/AIDS in Central Java. The cumulative number of AIDS cases in Semarang, based on risk factors from 2007 to December 2011, are heterosexual (74% of AIDS cases), intravenous drug users (IDU) (12% of AIDS cases), homosexual (3% of AIDS cases), bisexuals (3% of AIDS cases), perinatal transmission (2% of AIDS cases) and others are not known (6% cases).
One of the key populations with HIV prevalence above 5% based on Integrated Biological and Behavior Surveillance (IBBS) in 2011 is the population of Gay, Transgender

Introduction
HIV/AIDS has now become a serious health problem in many countries around the world. The number of the disease consistently rises up in a short time. The fatality of the disease progresses and there is no effective drug for the cure. Within the last 27 years, HIV infection has spread widely throughout the world. AIDS Commission says that HIV has infected more than 65 million people worldwide and nearly half of them have died. AIDS is ranked the fourth leading cause of death in adults worldwide.
The number of AIDS cases in Indonesia in 2010 to 2011 has risen from 24.131 cases to 28.757 cases. The data until December 2011 shows that Central Java is ranked 6th highest of HIV/AIDS cases in Indonesia with 3.531 HIV cases and 1.602 AIDS cases. Meanwhile, circumstances, there are some men who want to experiment with this technique. Based on the data from Integrated Biological And Behavioral Surveillance (IBBS) in 2007 in 5 cities, over 90% of transvestite perform anal and oral sex, in addition to the client, and 40-50% of transvestite have a regular partner, they call with husband. In Semarang, there are 47.5% transvestite who have a regular partner (husband).
Transvestite doing anal sex with their regular partners is common. Based on IBBS 2011, the regular partners of Transvestite barely use condoms in doing sex with them, which is less than 50%. The use of condom between transvestite with their regular partners is low because they are comfortable and trust their regular partner. They also believe that using condoms reduces pleasure in sexual intercourse.
The network of regular partners of Transvestite is very broad. The regular partners of Transvestite not only have sex with transvestite, but also have female sex partners or buy sex from women. Therefore, this increases the risk of the spread of HIV in homosexual or heterosexual population. But until now, there has been no program implemented on male regular partner of transvestite (husband of transvestite). Special initiatives are needed to reach regular partners of transvestite before they can receive correct information about HIV/AIDS as well as strategies to reduce the risk of contracting and transmitting HIV/AIDS.
In Semarang, the program targeting male regular partner of transvestite is not available yet. Programs that have been implemented are only limited to assist the HIV-positive sexual partners. The assisting program is, for instance, carried out by the NGO Graha Mitra that cares for vulnerable groups infected by HIV/AIDS in Central Java. Based on the data collection of NGO Mitra Graha Semarang, from 145 Transvestite in Semarang, the recorded number of regular partners of transvestite is 19 people, and 3 male regular partner of transvestite have status of HIV positive.
Health Belief Model is a cognitive model which is influenced by information from the environment. Possible individual will take preventive measures depending directly on the outcome of the two beliefs or health belief which is the perceived threat of injury or illness or Trasvestite, and Men who have sex with men (MSM) consisting of a population of transvestites with a prevalence of 22% and gay with prevalence of 8.5%. This case has increased from the previous year. STBP in 2009 mentions that HIV prevalence of transvestites in Indonesia is 18.96%.
Since the discovery of HIV/AIDS cases in Indonesia for the first time on male homosexuality in 1987, transvestites have received spotlight as a vulnerable group in HIV transmission. Almost all transgender or transvestite provide commercial sexual services and sexual intercourse with multiple partners.
Sex in transvestite community, in addition to oral sex, is often done with anal and a variety of other techniques that are not found in commercial female sex workers. The anal intercourse has higher risk for HIV transmission than vaginal intercourse because of frequent injuries to the anal area. It would be worse if they have sex without protection. Transmission of sexually transmitted diseases or HIV on transvestite is most likely to occur through unsafe sex without condoms, either in oral sex or anal sex. A study from Kelly (2012) reveals that nearly 50% of men liking men have reported their unprotected anal sex, often with casual partners of unknown HIV status and with many couples.
A research from Chapman (2011) in Rwanda finds that the prevention of HIV/AIDS among men who have sex with men (MSM) remains a serious problem and has not been addressed because of a very strong cultural resistance. The risk of HIV/AIDS of MSM is high because, in addition to having sex with men, they also have sex with women. Not a few of them are commercial sex workers as well. They have low condom use during anal and vaginal sex and high mobility of sexual activities. Sirivongrangson (2012) finds that HIV prevalence in MSM in Thailand is high. This is because risky sexual behavior among their other sexually active both with men and women, 32% without a condom, 41% had been diagnosed with a sexually transmitted infection (STI).
Anal sex is often performed by transvestites to their regular partners than clients (casual partners). In certain and consideration of the benefit and cost.
Components of the Health Belief Model (HBM) are: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action such as: a mass media campaign, the doctor's advice, etc. The others can be influenced indirectly related to behavior.

Method
This research used descriptive study with qualitative approach. Key informants in this study were the men who were male regular sexual partners of transvestite in the city of Semarang. The procedure of key informant selection was carried out using key informants (peer educator/ PE of transvestite) by using purposive sampling to select informants who truly had specific characteristics, namely men who became regular sexual partners of transvestite and lived at home together with transvestite and were willing to be the subject of research as well as provided information during the interview. The key informants consisted of 6 male regular sexual partners of transvestite. The supporting informants in this study consisted of a 3 people: 2 transvestite peer educators and 1 HIV Program Manager of Graha Mitra NGO who routinely conducted outreach program on transvestite in Semarang.
The data collection in this study was conducted through in-depth interview with male of regular partners of transvestite (key informants), peer educators of transvestite and HIV program manager Mitra Graha NGO Semarang for the crosscheck. The data collection began with the approach to PE of transvestite. Through transvestite PE, the information about transvestite who had regular partners was obtained. The researchers then approached transvestite who had regular partners in Cebongan (transvestite prostitution) in Tanggul Indah Semarang. Starting from transvestite prostitution, the familiarity was built and trust was gained. Researchers began asking permission to transvestite be able to meet with their regular partners. Researchers determined the right time to meet with their sex partners. The time required from the observation phase, the discovery of informants, establishing trust and interviews with informants took 8 months.
Data collection was done on each informant on average six times during the research process. This was due to the difficulty of adjusting to the availability of informant. Besides, it was also due to the completeness of the information. The interviews were mostly done at night because most of the new informants returned home from at 8 p.m.
The study employed open data analysis by using an inductive process, meaning that the hypothesis testing was started from the data gathering and finally concluded. Inductive thinking process was started from the data collection then the data was concluded in general. Data processing was done by descriptive contents based on the sequence of themes that were examined (thematic contents analysis) which was started from the description of sexual behavior in order to prevent the spread of HIV/ AIDS including behavior of using condoms and lubricant. Then it was followed by factors which were believed to be the determinant of behavior prevention of HIV/AIDS according to the study of theory Health Belief Model.

Results and Discussion
The results and discussion of this research are explained as follows: 1) The sexual behavior regular partners of transvestite in the prevention of HIV/AIDS, 2) The knowledge regular partners of transvestite on HIV/AIDS, 3) The perception regular partners of transvestite on susceptibility of contracting HIV, 4) The perception regular partners of transvestite on the AIDS severity, 5) The perception regular partners of transvestite on the perceived benefits in preventing the spread of HIV/AIDS, 6) The perception regular partners of transvestite about barrier in efforts to prevent the spread of HIV / AIDS, 7) Perceptions of regular partners of transvestite on the ability of self-efficacy in order to prevent the spread of HIV/AIDS, 8) A contributing factor to take steps to prevent the spread of HIV/AIDS (cues to action).
Three informants have never used condoms when having sex with transvestite. The reasons for not using a condom are because they think love and trust within relationship toward their partners and condom are believed to reduce the pleasure of sexual intercourse. Three informants express that sometimes they use of condoms when having sex with a transvestite because they do not want to get disease and fear of venereal disease. However, they sometime do not use condoms because they believe that condom reduces sexual pleasure and they want sexual sensation without using condom. As for the statements of informants can be seen in the following excerpt: "... Yes, sometime we use it and sometime we don't... depending on whether I want to use it or not. Sometime I feel anxious about the sexual disease too, mbak. It is because waria also also hang out... "(in-depth interview, regular partner of transvestite 1, 39 years old) "…Never, mbak. I feel that he is my own husband. I cannot feel pleasure if we use condom, no pleasure ... "(in-depth interview, regular partner of transvestite 5, 26 years) Low awareness on condom use among regular partners of transvestite is in line with the research of Saxton (2012). In a study on the use of condoms in New Zealand, it is found that condom use with regular sex partners is much lower than with a casual partner or spouse who pays. The sense of ownership and high emotional bond is considered as a factor that weakens the practice of condom use in regular sex partners. This study is also in line with research by Malonzo (2012) which states that the respondents feel happy and express their sexual needs and desires to demonstrate to their sexual partners that they are very special that made sex more enjoyable without a condom.
In this study, there is one informant who states that they do not have anal sex since three months ago when his transvestite partner is positive for HIV. While the informant is VCT and is declared negative, the sexual relations are conducted for the current oral sex without condom. The informants have confidence if oral sex will not transmit HIV. In fact, oral sex remains at risk in HIV transmission, especially without using condoms in couples who are already HIV positive, of course, very risky for transmitting HIV.
"... Now it is not, we do not use condoms because we never do anal sex anymore, because no entry in the anus. The oral sex does not use condoms because the lube tastes bad taste in the mouth... "(Indepth interview, regular partner of transvestite 4, 22 years) The action taken by this regular partner of transvestite is right if we want to reduce the risk of contracting HIV/AIDS. It is because the mikrolesi which is easily formed when the activity URAS (Unprotected Receptive Anal Sex) is thought to play an important role for the transmission of HIV through anal sex. This is in line with research on HIV positive MSM community in the United States who states that the MSM who have partners report that after they are tested positive for HIV, they change their sexual behavior from unsafe to be safe. The MSM reports that they practice safe sex by using condoms for anal sex and avoid oral sex with ejaculation. In addition, they agree not to perform oral sex without ejaculation and refrain from engaging in anal sex (Kesteren, 2005).
Four informants state that they always have sexual intercourse with female friends, wives and buy sex from female sex workers. One informant states that other than sexual intercourse with female sex workers, he also has sex with his legal wife. Five informants sometimes they use condoms when having sex with female sex workers. The regular partners of transvestite admit that condom use is based on the beauty of women. They think that because they pay to buy sex so they are not satisfied if they use condoms. They also look at the hygiene of vagina, depending on the prostitute after sexual intercourse with another person. The statement quoted the regular partners of transvestite is stated below: "... Sometimes, depending on the person. Some use a condom, sometimes does not.. if the woman is beautiful, I do not use condom, depending on the woman because I pay. If she wants, I do not use condoms. Actually, I prefer not to use condoms ... "(in-depth interview, regular partner of transvestite 1, 39 years old) "…Sometimes, depending on the mood, Miss. Yes, if I think that she is beautiful and clean, I will not use a condom. But if she looks like she has just played with someone else, I will use condoms.. because my friend also works as female sex workers via phone, but with me, I don't have to pay, if she has sex with customers, they must pay ... "(indepth interview, regular partner of transvestite 4, 22 years old) The result of the study shows that transvestite and their regular partners who also have another sex partners (homosexual or bisexual) will be the entry bridge of HIV into the community. Men who have unprotected anal sex with men not only cause him a high risk, but also make the wife, girlfriend, more sex partners, and their babies to be also at high risk for contracting HIV or other STDs. This study is in line with research of Rokhmah (2015) which states that sexual behavior of transvestites is highly risky in the transmission of HIV/AIDS by doing oral and anal sex with multiple partners without using condoms and lubricant.
The use of lubricant on the two informants are not consistent with the use of lubricants that are not water material such as hand body lotion (oil-based) which is very easy to cause injury in the anus and in the risk of HIV transmission.
"... use hand body, sometimes I use it occasionally but not often... " (indepth interview, regular partner of transvestite 1, 39 years old) The use of a lubricant which is not from water material will give discomfort (heat) in the anus and penis and can lead to a torn condom. If condoms and lubricants are used properly, then anal sex is not too dangerous to damage anus.
The key is to relax the anal sphincter muscle, and most importantly, by using water-based lubricant (like KY cream) appropriately, the pain will not be felt during intercourse. Water based lubricant will not damage the condom during use, in contrast to oil-based lubricants which can result in a torn condom.
In other words, the use of lubricants as prevention of HIV transmission to transvestite and their regular sex partners is still low. This is similar to Rokhmah (2015) who states that the sexual behavior of transvestite nd their sex partner has high risk in the transmission of HIV/AIDS by doing oral and anal sex with multiple partners without using condoms and lubricant.
The This finding is also consistent with research of Argyo about MSM (Men Who Have Sex with Men) in Surakarta which states that the MSM knowledge related to HIV/AIDS in terms of its definition is not yet fully clear and well understood by the MSM community. It is evident that on the interpretation of the concept of HIV/AIDS, they just rely on the knowledge which is understood and spoken in a practical or likely to be excluded. In terms of definition with no absolute truth to support it, they still believe that they know about HIV/AIDS as an illness or a deadly virus despite the fact that such understanding can misguide or have a fatal degree of misperception (Dermatoto, 2013).
MacDaid (2010), states that poor knowledge of HIV status will affect the behavior of MSM in reducing HIV transmission risk behaviors. This study is also consistent with research of Azam (2014) which states that the low knowledge of prostitutes about HIV/AIDS, the bad attitude on condom use, and the lacking information received prostitutes are factors that can prevent the success of condom use for the customers. Besides, the inability of prostitutes in doing condom negotiation would also weaken the practice of condom use among them. The same research also states that the other factors which are associated with the poor use of condoms are prostitutes knowledge about STDs and HIV/AIDS, prostitutes attitudes towards condom use, as well as information access about STDs and HIV/AIDS (Boediono, 2012).
Three informants feel non-vulnerable to HIV because they still feel good about their body condition, not suffering from HIV despite multiple sexual partners, think that their transvestite partners are clean from the disease, and they are no longer changing sexual partners. Three informants who are vulnerable to HIV infection by reason many transvestites who suffer from HIV and transvestites are very vulnerable to HIV due to frequent anal sex with multiple sexual partners and feel vulnerable to HIV transmission because their partner is a transvestite who suffer from HIV.
"... no no, I don't think so, never have any problem. I have never had disease like that. I'm okay anyway, I also have sex with transvestite and female prostitutes also. The disease really depends on the person too ya ya ya ... "(in-depth interview, regular partner of transvestite 1, 39 years) "... really easy.. the reasons..must be answered, mustn't it? Because I live with people with HIV, imel is HIV positive. She was diagnosed 3 months ago, after since we have not done any anal sex, just oral sex ... "(in-depth interview, regular partner of trasvestite 4, 22 years old) The finding is in accordance with the research of Azam (2014) on female Sex Workers (FSW), which states that the FSW have a belief that if their body condition is healthy, they do not need to use condom when serving customers. Conversely, if they are sick, they would force customers to use condom. Unfavorable attitude toward the use of condoms in risky sexual behavior that they do is that they take no need to use condom when having sex with a boyfriend or a regular customer.
Five informants claim that AIDS is a dangerous disease because HIV/AIDS is transmitted through sexual intercourse, it cannot be cured, they fear death, there is no medicine that cures disease AIDS can also transmit the virus to their children and they fear to be isolated by communities.
"... Yes, of course dangerous, the danger is that it has no cure, Yes, I am scared to death ... " (in-depth interview, regular partner of transvestite 3, 51 years old) This is in line with MacKellar (2007)  This finding is in line with the theory of the Health Belief Model by Rosenstock; if the perception of the threat of a disease is low, then a highly positive perception is still able to influence the behavior of condom use.
Two informants claim to have obstacles in accessing condoms because they are embarrassed to have to buy condoms in pharmacies and feel lazy if they have to buy condoms. This is because it is expensive and their transvestite partners get free condoms from the KPA (Komisi Penanggulangan AIDS/ AIDS Control Commission). Because they are used to get everything for free, regular partner of transvestite feel a loss when they must spend money to buy condoms when free condoms are not available.
"... I want to buy but I am too embarrassed. Miss Vera with the partner do not use condom.... because at night after working, I am very exhausted... "(in-depth interview, Regular partners of Transvestite 2, 23 years old) The access to condoms is good if someone gets the condom by buying and knowing the places to easily buy condoms easily. Meanwhile, poor access is when someone just wants to always get free condoms and do not know the places to buy condoms easily, in addition to a place where they get free condoms. The informants states that the obstacles in the use of condoms are it feels horrible, less pleasure in sexual intercourse, uncomfortable feeling like a penis wrapped in rubber, feel the pain of the condom is too tight, and used rubber makes it a pain when urinating.
" The result is consistent with Silan (2013) who states that condom use with a male partner is low (46%). The most common reason (52%) for not using condoms is because condom is not available and the couples do not want to use traditional condoms.
Five informants never ask their sexual partner to use a condom and informants also do not intend to prepare a condom before intercourse. All informants never negotiate to use condom. And the use of condom is as they wish.
"... If he wants to not use condom, that's ok ... Actually, I do not use condoms, miss, especially if she is pretty ... " (in-depth interview, regular partner of transvestite 1, 39 year old) "... If the same PSK sometimes just use condoms, I will see the girl first.
When I see the girl is clean, I do not use condoms and it's okay ... " (indepth interview, regular partner of transvestite 6, 33 years old) The results of this study are also in line with research from Azam (2014). The study reveals that many Female Sex Workers (FSW) still have negative attitude (unfavorable) on the use of condoms. It can be seen from the assumption that sexual intercourse using a condom can reduce sexual pleasure and doing the intercourse with clean man will not transmit any disease. Many of them are still willing to serve the customers despite not using condoms as long as they pay higher than usual rates. In addition, they also have a belief that if their body condition is healthy. They do not need to use condom when serving customers. Conversely, if their customers are sick, they would force them to use condom.
Two informants are motivated to do the prevention of HIV/AIDS because of the influence of transvestite friends. Their transvestite friends who frequently visit their rented house always remind them to use condoms, especially when they want to do intercourse with transvestite who are HIV positive. Two informants are compelled to undertake HIV/AIDS prevention for themselves because they realize that they are vulnerable to get HIV and fear of contracting HIV from their partners.
"... Yes, because I live with people with HIV. So when I have intercourse with Imel, I must use condom, avoid anal sex, so it's just oral sex when I play with imel ... " (in-depth interview, regular partner of transvestite 4, 22 years old) "... Yes, my transvestite friends always say that we should use condoms because my partner is HIV positive... " (in-depth interview, regular partner of transvestite 6, 33) The research from Rista (2012) mentions that the perception of risk is also a driving factor which reinforces self-motivation and readiness to change behavior. Informants who recognize and define themselves as people who are at high risk for HIV transmission tend to have the motivation and readiness to change behavior more robust and consistent. In addition, the risk perception is strengthened based on direct experience (never IMS, never VCT, direct view of PLWH (People Living with HIV/AIDS), seeing his friends in pain). Therefore, the perception is not only based on the artificial knowledge, but also from critical risks by understanding the informant will be their surrounding situation and the negative impact which might come.

Conclusion
The use of condoms and lubricant by regular partner of transvestite is still low. They are inconsistent in conducting the sexual activities, sometime with transvestite their partners or with other sexual partner. The knowledge of HIV/AIDS in male regular partner of transvestite is still not good. Most informants feel vulnerable to HIV transmission because they think that their body condition is still good despite the frequent change of sexual partners, their transvestite partners are clean and faithful to one sexual partner. Most informants claim that AIDS is a dangerous disease because the disease cannot be cured and they are scared for being discriminated by society. Most informants state that condom is helpful. However, they all have obstacles in the use of condoms because they think that condom reduces the intercourse pleasure and uncomfortable. The transvestite also have low self-perception abilities because they never ask their sexual partners to use condoms and do not intend to prepare a condom before intercourse.