{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T00:56:25Z","timestamp":1789952185304,"version":"4.0.1"},"reference-count":40,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2021,5,28]],"date-time":"2021-05-28T00:00:00Z","timestamp":1622160000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Transgender populations are considered as a highly vulnerable group to HIV infection. This study aimed to understand structural, personal and socioenvironmental factors and the mechanisms through which these factors facilitate HIV transmission among transgender women (waria) in Yogyakarta, Indonesia. A qualitative inquiry using one-on-one in-depth interviews was employed to collect data from participants (n = 29). Thematic analysis was used to guide data analysis. Findings showed that poverty in families, a sense of responsibility to support family necessities, limited employment options and low education attainment were the structural factors driving participants\u2019 engagement in sex work practices and unprotected anal intercourse, which facilitated HIV transmission among them. Personal need fulfilment and the desire for savings were personal factors driving their engagement in these high-risk practices that supported HIV transmission. Social relationships, social influence and the participants\u2019 living environment were socioenvironmental factors that also supported sex work practices and HIV transmission among the participants. The findings indicate the need for capacity building in terms of knowledge and skills for waria populations to prepare and enable them to gain meaningful employment to prevent the vicious cycle of HIV transmission among them. As structural factors seemed to be the main drivers predisposing waria to HIV acquisition, further studies to explore effective HIV\/AIDS interventions that address economic aspects of waria in Yogyakarta and other similar settings in Indonesia are recommended.<\/jats:p>","DOI":"10.3390\/ijerph18115814","type":"journal-article","created":{"date-parts":[[2021,5,28]],"date-time":"2021-05-28T11:33:20Z","timestamp":1622201600000},"page":"5814","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Structural, Personal and Socioenvironmental Determinants of HIV Transmission among Transgender Women in Indonesia"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1325-2640","authenticated-orcid":false,"given":"Nelsensius Klau","family":"Fauk","sequence":"first","affiliation":[{"name":"College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia"},{"name":"Institute of Resource Governance and Social Change, Jl. R. W. Monginsidi II, No. 2, Kupang, Nusa Tenggara, Timur 85221, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Silvia","family":"Merry","sequence":"additional","affiliation":[{"name":"Medicine Faculty, Duta Wacana Christian University, Jl. Dr. Wahidin Sudirohusodo, No. 5-25, Kotabaru, Yogyakarta 55224, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Theodorus Asa","family":"Siri","sequence":"additional","affiliation":[{"name":"Saint Peter Pastoral Institute of the Diocese of Atambua, Kefamenanu, Nusa Tenggara, Timur 85613, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5792-7785","authenticated-orcid":false,"given":"Lillian","family":"Mwanri","sequence":"additional","affiliation":[{"name":"College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5559-9714","authenticated-orcid":false,"given":"Paul Russell","family":"Ward","sequence":"additional","affiliation":[{"name":"College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,5,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1071\/SH07045","article-title":"Sex trade in a male-to-female transgender population: Psychosocial correlates of inconsistent condom use","volume":"5","author":"Guzman","year":"2008","journal-title":"Sex. Health"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1193","DOI":"10.2105\/AJPH.94.7.1193","article-title":"HIV risk behaviors among male-to-female transgender persons of color in San Francisco","volume":"94","author":"Nemoto","year":"2004","journal-title":"Am. J. Public Health"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1177\/00333549081230S313","article-title":"Rapid HIV testing in transgender communities by community-based organizations in three cities","volume":"123","author":"Schulden","year":"2008","journal-title":"Public Health Rep."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"(2021, April 01). UNAIDS. UNAIDS Data, The Joint United Nations Programme on HIV\/AIDS: Switzerland, Available online: https:\/\/www.unaids.org\/en\/resources\/documents\/2020\/unaids-data.","DOI":"10.31947\/hjirs.v1i1.12738"},{"key":"ref_5","unstructured":"Kementerian Kesehatan, R.I. (2021). Laporan Situasi Perkembangan HIV\/AIDS Dan PIMS di Indonesia, Januari-Desember 2020, Kementerian Kesehatan Republik Indonesia."},{"key":"ref_6","unstructured":"Guyer, H. (2021, April 01). Waria: The Lives of Indonesia\u2019s Transgender Women Indonesia: Cultural Trip. Available online: https:\/\/theculturetrip.com\/asia\/indonesia\/articles\/waria-lives-indonesias-transgender-community\/."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Butt, L., and Eves, R. (2016). \u201cIt\u2019s Mutual Attraction\u201d: Transvestites and the Risk of HIV Transmission in Urban Papua. Making Sense of AIDS: Culture, Sexuality, and Power in Melanesia, University of Hawaii Press.","DOI":"10.1515\/9780824863470"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"536","DOI":"10.1136\/sti.2003.007500","article-title":"HIV, syphilis infection, and sexual practices among transgenders, male sex workers, and other men who have sex with men in Jakarta, Indonesia","volume":"80","author":"Pisani","year":"2004","journal-title":"Sex. Transm. Infect."},{"key":"ref_9","unstructured":"Pusat Penelitian Kesehatan Universitas Indonesia (2015). Pandangan Transgender Terhadap Status Gender dan Persamaan Hak Asasi Manusia di Jakarta, Bogor, Depok dan Tangerang, Kementerian Permberdayaan Perempuan dan Perlindungan Anak."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1177\/1557988313508430","article-title":"Condom Use Among Men Who Have Sex With Men and Male-to-Female Transgenders in Jakarta, Indonesia","volume":"8","author":"Safika","year":"2014","journal-title":"Am. J. Men\u2019s Health"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1525\/can.2004.19.2.159","article-title":"Playing Back the Nation: Waria, Indonesian Transvestites","volume":"19","author":"Boellstorff","year":"2004","journal-title":"Cult. Anthropol."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Fauk, N.K., Merry, M.S., Sigilipoe, M.A., Putra, S., and Mwanri, L. (2017). Culture, social networks and HIV vulnerability among men who have sex with men in Indonesia. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0178736"},{"key":"ref_13","unstructured":"Budiman, A. (1979). Lelaki Perindu Lelaki: Sebuah Tinjauan Sejarah Dan Psikologi Tentang Homoseks Dan Masyarakat Homoseks di Indonesia, Satya Wacana."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"915","DOI":"10.2105\/AJPH.91.6.915","article-title":"HIV prevalence, risk behaviors, healthcare use, and mental health status of transgender persons: Implications for public health interventions","volume":"91","author":"Marx","year":"2001","journal-title":"Am. J. Public Health"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1016\/j.jana.2009.06.005","article-title":"HIV Infection Risk Factors Among Male-to-Female Transgender Persons: A Review of the Literature","volume":"20","year":"2009","journal-title":"J. Assoc. Nurses AIDS Care"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"768","DOI":"10.1007\/s10508-007-9210-3","article-title":"Perceived risks and benefits of sex work among transgender women of color in San Francisco","volume":"36","author":"Sausa","year":"2007","journal-title":"Arch. Sex. Behav."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1023\/A:1018765132704","article-title":"Gendered sex work in the San Francisco Tenderloin","volume":"28","author":"Weinberg","year":"1999","journal-title":"Arch. Sex. Behav."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1080\/09540129850124028","article-title":"Transgender HIV prevention: A qualitative needs assessment","volume":"10","author":"Bockting","year":"1998","journal-title":"AIDS Care"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1030","DOI":"10.2105\/AJPH.2006.097717","article-title":"Male-to-female transgender and transsexual clients of HIV service programs in Los Angeles County, California","volume":"97","author":"Edwards","year":"2007","journal-title":"Am. J. Public Health"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1177\/1049732308324247","article-title":"Knowledge legitimacy: How trans-patient behavior supports and challenges current medical knowledge","volume":"18","author":"Dewey","year":"2008","journal-title":"Qualit. Health Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"418","DOI":"10.1136\/sti.2006.020628","article-title":"Sex worker health: San Francisco style","volume":"82","author":"Cohan","year":"2006","journal-title":"Sex. Transm. Infect."},{"key":"ref_22","first-page":"102","article-title":"AIDS related attitudes and sexual practices of the Jakarta WARIA (male transvestites)","volume":"25","author":"Lubis","year":"1994","journal-title":"Southeast Asian J. Trop. Med. Public Health"},{"key":"ref_23","unstructured":"Wilkinson, W., and Marmot, M. (2005). Social Determinants of Health: The Solid Facts, World Health Organization. [2nd ed.]."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1016\/S0277-9536(00)00065-4","article-title":"From social integration to health: Durkheim in the new millennium","volume":"51","author":"Berkman","year":"2000","journal-title":"Soc. Sci. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"2","author":"Braun","year":"2006","journal-title":"Qual. Res. Psychol."},{"key":"ref_26","unstructured":"WHO (2010). HIV\/AIDS among Men Who Have Sex with Men and Transgender Population in South- East Asia: The Current Situation and National Responses, World Health Organization."},{"key":"ref_27","unstructured":"WHO (2012). Understanding the Modes of Transmission Model of New HIV Infection and Its Use in Prevention Planning, World Health Organization."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1177\/1557988318756132","article-title":"Perceptions of Determinants of Condom Use Behaviors Among Male Clients of Female Sex Workers in Indonesia: A Qualitative Inquiry","volume":"12","author":"Fauk","year":"2018","journal-title":"Am. J. Men\u2019s Health"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Januraga, P.P., Mooney-Somers, J., Gesesew, H.A., and Ward, P.R. (2020). The Logic of Condom Use in Female Sex Workers in Bali, Indonesia. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17051627"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/1471-2458-14-832","article-title":"Newcomers in a hazardous environment: A qualitative inquiry into sex worker vulnerability to HIV in Bali, Indonesia","volume":"14","author":"Januraga","year":"2014","journal-title":"BMC Public Health"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1097\/00126334-200301010-00012","article-title":"HIV Knowledge and Risk Factors Among Men Who Have Sex with Men in Ho Chi Minh City, Vietnam","volume":"32","author":"Colby","year":"2003","journal-title":"J. Acquir. Immune Def. Syndr."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"47","DOI":"10.5539\/gjhs.v9n8p47","article-title":"Exploring Determinants of Unprotected Sexual Behaviours Favouring HIV Transmission among Men who Have Sex with Men in Yogyakarta, Indonesia","volume":"9","author":"Fauk","year":"2017","journal-title":"Glob. J. Health Sci."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1071\/SH17137","article-title":"HIV susceptibility among clients of female sex workers in Indonesia: A qualitative inquiry","volume":"15","author":"Mwanri","year":"2018","journal-title":"Sex. Health"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1071\/PY07020","article-title":"Health Literacy in Primary Health Care","volume":"13","author":"Keleher","year":"2007","journal-title":"Aus. J. Primary Health"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/1475-9276-12-18","article-title":"Patient-centred access to health care: Conceptualising access at the interface of health systems and populations","volume":"12","author":"Levesque","year":"2013","journal-title":"Int. J. Equity Health"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Fauk, N.K., Kustanti, C.Y., Wulandari, R., Damayani, A.D., and Mwanri, L. (2018). Societal determinants of HIV vulnerability among clients of female commercial sex workers in Indonesia. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0207647"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1108\/IJHRH-10-2014-0028","article-title":"Inequalities in addressing the HIV epidemi: The story of the Indonesia Ojek community","volume":"8","author":"Fauk","year":"2015","journal-title":"Int. J. Hum. Rights Healthc."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1080\/19361653.2013.799000","article-title":"Sociocontextual Factors: Moving Beyond Individual Determinants of Sexual Risk Behavior Among Gay and Bisexual Adolescent Males","volume":"10","author":"Torres","year":"2013","journal-title":"J. LGBT Youth"},{"key":"ref_39","first-page":"84","article-title":"Abu-abu regulasi LGBT di Indonesia","volume":"4","author":"Sofyarto","year":"2018","journal-title":"SELISIK"},{"key":"ref_40","unstructured":"USAID (2020). Hidup Sehat Sebagai LGBT di Asia: Laporan LGBT Nasional Indonesia."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/11\/5814\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:09:51Z","timestamp":1760162991000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/11\/5814"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,28]]},"references-count":40,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2021,6]]}},"alternative-id":["ijerph18115814"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18115814","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,28]]}}}