1. Introduction

HIV had been a widespread health burden globally. The Joint United Nations Programme on HIV/AIDS (UNAIDS) data had estimated 39 million people living with HIV (PLHIV) in 2022 globally, wherein 1.3 million were newly diagnosed, and 0.63 million died from Acquired Immune Deficiency Syndrome (AIDS)-related illnesses in the same year [1]. The number of PLHIV in Asia and the Pacific region was 6.5 million, i.e., 16.6% of the global burden, of whom ~0.3 million were newly diagnosed and 0.15 million died in 2022 [2]. Key population groups (sex workers and their clients, MSM, people injecting drugs and transgenders) accounted for over 90% of new HIV infections in Asia and the Pacific region.

Indonesia had growing HIV epidemic with ~377,650 PLHIV till March 2023 [3]. The annual number of newly diagnosed HIV people had increased in the past decade from 21,511 in 2012 to 50,282 in 2019, and declined to 13,279 in March 2023 [3]. In 2023 alone, 29% of the total HIV cases in country were diagnosed in MSM population compared to 26.6% in 2021 [3]. Engagement in high-risk sexual behaviours including multiple sexual partners and taking alcohol or drugs before sex were the major contributing factors towards unprotected receptive and insertive anal intercourse for HIV transmission in them [4]. MSM and homosexuality had not been widely accepted in communities and regarded as the violation of socio-cultural and religious values in Indonesia [5]. This situation got complex when Indonesian parliament enacted a new criminal code on 06 December 2022, that included the provisions contradicting international human rights, laws, and standards. The provisions undermined fundamental rights pertaining to freedom of speech and association for individuals identified as lesbian, gay, bisexual, and transgender (LGBT) [6]. The prohibitive socio-cultural and religious values and norms against same-sex relations had thus been supportive of the factors for concealing sexual orientation, and engaging in unprotected sex because of the reluctance in accessing condoms to avoid negative judgement or labelling [7]. Factors such as subjective norms of MSM peers and perceived behavioural control had also influenced their intention and willingness in using condoms [8]. Other studies also reported that intimate partner violence had a strong negative impact on MSM’s condom usage [9, 10]. The MSM sex workers experiencing violence from partners were likely to engage in unprotected sex, and thus susceptible to HIV transmission [11, 12].

It had been suggested that interventions regarding health promotion would improve the knowledge and awareness about condom usage because the risky sexual behaviours had mainly contributed in HIV transmission among MSM populations. However, the findings of a study in Bali had demonstrated that good level HIV knowledge was not always translated into protected sex, positive health information-seeking behaviour, and HIV treatment compliance among MSM [13]. Understanding of their health information-seeking behaviours regarding HIV/AIDS was thus essential. A study in Vietnam had reported that MSM would seek information of HIV/AIDS and STIs, and search for sex partners via mobile apps, websites or dating apps [14]. Similarly, a study in Indonesia had found that MSM used mobile or dating apps to find sex partners and build MSM specific social networks [7]. The online platforms could thus be benefitted for health promotion and intervention in HIV transmission to target MSM populations in the Indonesian context.

The existing literature provided limited evidence on (i) HIV and STIs related health information-seeking behaviours; and (ii) the link between intimate partner violence and condom usage, among MSM in Indonesia. This study was thus aimed to fill these gaps by exploring health information-seeking behaviours, intimate partner violence, and sexual risk-taking among MSM in Bali, Indonesia. Understanding these aspects would be beneficial for improving HIV services to MSM populations, developing HIV policy and interventions to address their needs, and support their access to condoms, and HIV care and treatment.

2. Materials and methods

3. Results

The characteristics of study participants regarding personal factors, health information-seeking behaviour, intimate partner violence, and sexual behaviour are given in Table 1. More than one-quarter of MSM were 26–30 years old (30.30%). About 70.30% MSM lived in Denpasar. More than three-quarters of MSM were employed (78.79%). More than three-quarters of MSM identified themselves as homosexual (89.09%). Almost all MSM (97.58%) never sought STIs information as per the health information-seeking behaviour. More than three-quarters had never pursued for information about HIV prevention (80.00%). More than one-half of MSM never inquired about HIV treatment (60.61%), HIV test service (58.79%) and antiretroviral therapy (ART) service (66.67%).

MSM also experienced violence from their partner. About 24.24% MSM faced psychological violence, 37.58% verbal violence, 20.61% physical violence, and 16.97% sexual violence from the partner. More than two-thirds (67.88%) of MSM were engaged in transactional sex, while more than three-quarters (78.79%) had sex under the influence of drugs or alcohol in the last six months. Only 28.48% MSM had multiple (more than one) sex partners. There were 21.79% MSM infected by STIs in the last six months wherein 16.36% were HIV positive. About 32.73% MSM were never tested or did not know their HIV status. About 23.03% MSM had inconsistently used condoms.

Fig. 1 exhibits the percentage of MSM experiencing any type of IPV like single and multiple. Among single type of IPV, 4.1% MSM experienced psychological violence, 18.9% verbal, 4.1% physical, and 5.4% sexual. Furthermore, 16.2% MSM suffered all types of violence. The detailed MSM proportions experiencing multiple types of IPV could be seen in the Venn diagram (Fig. 1).

Fig. 1. Types of intimate partner violence experienced by MSM (n = 165).

The prevalence of unprotected sex among MSM by characteristics such as intimate partner violence, and health information-seeking behaviour (Table 2). The unprotected sex prevalence was higher (p = 0.029) in those experiencing verbal violence (32.26%) compared to who never experienced it (17.48%). The unprotected sex prevalence was higher (p = 0.018) in those with physical violence (38.24%) compared to who never experienced it from their partner (19.08%). Regarding sexual behaviour, the unprotected sex prevalence was higher (p = 0.014) in those involved in transactional sex (28.57%) compared to who never engaged in this (11.32%). The unprotected sex prevalence was higher (p = 0.017) in MSM having one sexual partner (27.97%) compared to with multiple sexual partners (10.64%).

The prevalence of HIV and STIs cases by characteristic like types of intimate partner violence, and health information-seeking behaviour in MSM (Table 3). The HIV-positive prevalence was higher (p < 0.001) in MSM who searched for information about HIV treatment (32.31%) compared to who did not (6.00%). HIV-positive prevalence was higher (p = 0.011) in MSM searching for information about ART services (23.64%) compared to who did not (12.73%). STI-positive prevalence was higher (p = 0.048) in MSM searching for information about HIV services (29.41%) compared to who did not (16.49%). STI-positive prevalence was higher (p = 0.016) in MSM searching for information about ART services (32.73%) compared to who did not (16.36%). STI-positive prevalence was higher (p = 0.033) in MSM experiencing verbal violence (30.65%) compared to who did not (16.50%). STI-positive prevalence was higher (p = 0.028) in MSM never involved in transactional sex (32.08%) compared to who were involved (16.94%). STI-positive prevalence was higher (p = 0.047) in MSM with multiple sexual partners (31.91%) compared to with single sexual partner (17.80%).

4. Discussion

This study finding would improve the HIV and STI programs for reducing their transmission among the MSM population in Bali, Indonesia. It was found herein that transactional sex was associated with unprotected sex. MSM engaged in transactional sex to attain particularly the socioeconomic benefits from partners [15]. Transactional sex might create imbalance in power relations to lead into intimate partner violence among MSM [16]. The sexual partner type was also linked with transactional sex wherein romantic MSM partners were engaged in unprotected sex as an expression of love to the partner [17], which in turn increased the HIV and STIs transmission risk [18].

A study in United States had highlighted that MSM considering the relationship as serious tended to perform unprotected sex with partner [19]. MSM with single sexual partner faced difficulties in negotiating for condom usage, especially if they considered the partner as romantic [20]. The same had been reflected in this study where MSM with only one sexual partner had higher prevalence of unprotected sex compared to with multiple partners. Contrarily, MSM with multiple sexual partners had higher STI prevalence compared to with single partner. The findings indicated that condom negotiation and condom usage in MSM population was crucial issue to be addressed via HIV and STI interventions to prevent their transmission among them. Furthermore, limited HIV and STI programs on transmission prevention in MSM population were found in the study setting and Bali, Indonesia in general.

This study found that the unprotected sex prevalence in MSM experiencing verbal and physical violence was higher compared to who did not experience them. A higher STI prevalence was also found in MSM experiencing verbal violence. This might imply that IPV could increase the HIV transmission risk and cause mental health problems in MSM [21]. This could worsen the overall health condition of MSM because they already had suffered from social pressure, multiple layers of stigma, and discrimination [22]. A comprehensive meta-analysis involving 13,797 participants depicted that IPV not only increased the likelihood of substance usage but also led to the higher prevalence of depressive symptoms, HIV positivity, and engagement in unprotected anal sex in MSM [23].

Some studies depicted that IPV had detrimental impact on MSM mental health. Studies conducted in Guatemala and China revealed that experiencing IPV raised the anxiety and depression in MSM individuals [21, 24]. Serious mental health problems could reduce ART retention and adherence in MSM [25]. MSM experiencing IPV had been reported to less likely access the HIV testing [26]. Thus, HIV-related health outcomes could be enhanced in MSM with IPV history by prioritizing mental health as a focal point for intervention [27]. A strategy could involve the integration of HIV services, mental health services, and IPV prevention. Providing mental health services could also increase the uptake of HIV testing and PrEP in MSM [28]. A study in Japan found that the integration of HIV and mental health services increased the treatment retention in PLHIV [29]. IPV screening was imperative in providing mental health services to MSM experiencing violences [29]. Implementing a community-based intervention in MSM communities could improve the access to IPV screening and mental health services for MSM individuals [30]. It was thus crucial for the governments’ and non-governmental organisations’ HIV programs to provide mental health services and IPV prevention.

This study found that above three-quarters of MSM had searched for information about HIV prevention. In contrast, less than one-half of MSM had searched for information about STI prevention, HIV test service, and ART service. MSM in this study lacked information on STIs, HIV tests, and treatments which could lower the uptake of HIV and STIs tests, and non-engagement in treatment programs [31]. Several factors could contribute to persistent problems regarding HIV-related knowledge and limited access to information on HIV and STI prevention in MSM. MSM in Indonesia were often compelled to conceal identities out of societal stigma, fear thereof, and potential criminalization [32]. Conducting HIV programs regarding outreach and health promotion to reach MSM population became difficult in such situation [33]. Conversely, MSM in Indonesia mostly employed secretive platforms such as mobile and web applications to meet other men for sex [34]. Health promotion targeting the MSM population through these platforms could thus be a strategy to improve the MSM knowledge related to HIV and STI [35].

HIV programs could employ a collaborative approach in delivering health promotion, especially by empowering the social network and digital platform used by MSM as communication media [36, 37]. Studies in China and the United States found that providing information and HIV-related services through digital platforms (e.g., mobile health and websites) had increased the engagement of MSM population in accessing HIV-related services [38, 39]. MSM preferred to communicate via digital platform as it provided exclusive and safe environment to interact with others. Providing health information through digital platform was thus a good strategy to access comprehensive information about HIV and STIs in MSM population.

The present study had certain limitations. It was unable to establish causality or draw inferences because of a cross-sectional approach with convenient sampling. Furthermore, the online survey relied on self-reporting which introduced the possibility of recall bias, self-bias, and a tendency to provide socially desirable responses. The duplicate phone numbers were removed during the data validation process of this study. However, it was possible for the multiple families to share the same number. This exclusionary practice could result in systematic bias. Despite these constraints, the study provided valuable insights into the health information-seeking behaviour, intimate partner violence, and sexual risk-taking in the MSM community of Bali, Indonesia. The outcomes of this online survey could be a foundational reference for conducting qualitative studies in future.

5. Conclusions

Most participants of this study consisted of MSM aged 26–30 years, residing in Denpasar, employed, identified as homosexual, not infected by recent STIs, and HIV negative. Pertaining to the trends in health information-seeking behaviour, over one-third of MSM searched for information on HIV prevention, while less than half sought information on STI prevention, HIV treatment, HIV testing services and ART services. The unprotected sex prevalence varied and was associated with physical and verbal violence, transactional sex, and the number of sexual partners. Consequently, the health promotion efforts targeting the MSM community should prioritize STI prevention, HIV treatment, HIV testing services, ART services, and address the impact of intimate partner violence.

Availability of data and materials

The data from this study can be made available upon reasonable request to the corresponding author.

Author contributions

NPAH—responsible for conceiving the idea; prepared the initial draft of the manuscript. NPAH and DSL—analyzed the data. PPJ—oversaw the English proofreading and managed the APC (Article Processing Charge) costs. NPAH, PPJ, DSL, HAG, NKF and PRW—critical review the manuscript and approval for its final version. All authors made significant contributions to the development of the article and have approved the version submitted for publication.

Ethics approval and consent to participate

The studies involving human participants underwent a review and received approval from the Research Ethics Commission at the Faculty of Medicine, Udayana University/Sanglah General Public Hospital, Bali Province, Indonesia (No. 1335/UN 14.2.2/V.I.I/4/T/2020). Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the participants to publish this paper.

Acknowledgment

We express our gratitude to the Center for Public Health Innovation, Faculty of Medicine Udayana University, for facilitating the research permits and funding the study. We would also like to extend our appreciation to all the study respondents for generously devoting their valuable time and effort to complete the questionnaire.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.

Supplementary material

Supplementary material associated with this article can be found, in the online version, at https://oss.jomh.org/files/article/1806557885571710976/attachment/Supplementary%20material.docx.