Sexual Behavior and HIV / AIDS Prevention in Male Sexual Men (MSM) in Denpasar City

HIV / AIDS cases among MSM (male sex men) in Indonesia from year to year have increased significantly. Meanwhile, Bali is a province with many HIV / AIDS cases, where Denpasar is the city with the highest number of MSM. There has never been a report on sexual behavior and HIV / AIDS prevention among MSM in Denpasar. Therefore, the researchers wanted to explore the problems of sexual behavior and its prevention in MSM in Denpasar. Purpose: This study aims to obtain a vision of sexual behavior and HIV / AIDS prevention among MSM groups in Denpasar City. This study used a qualitative design with a phenomenological approach to digging deeper into sexual behavior and HIV / AIDS prevention among MSM in Denpasar City. The selection of informants in this study was taken using convenience sampling technique and conducted in-depth interviews with 10 MSM who were productive and communicative in Denpasar. After collecting data in the field, the data will be analyzed thematically. In sexual intercourse behavior, most of the MSM prioritized variations and sensations during sexual intercourse to get sexual satisfaction, such as having group sex, using arousal-enhancing drugs, and violence engaging during sexual intercourse. Some of the informants only had one permanent sexual partner. However, there are still MSM who have more than one sexual partner and receive payment for sexual intercourse. Informants use condoms in sexual intercourse and with the PrEP method to avoid HIV / AIDS. It is necessary to conduct education and counseling on sexual orientation for the community, especially for adolescents looking for identity, educating MSM to reduce high-risk behavior during sexual


METHOD
This research was conducted in 2020 utilizing a qualitative design with a phenomenological approach to picture sexual behavior and HIV / AIDS prevention in MSM groups in Denpasar City. In this study, the selection of informants was taken by convenience sampling technique. The informants in this study are MSM in Denpasar City. The inclusion criteria to select the informants are MSM with productive age (aged between 18-45 years), willing to become informants, communicate well, and willing to provide the information needed by the researcher.
The sample size in qualitative research is taken according to the researcher's needs which in this study is a maximum of 10 informants. The selection of informants was determined by convenience, where the sample selection was carried out in several stages. It was starting from the informant to all MSM who became his sexual partners and proceeded to the next level of sex partners according to the sexual network. Primary data were obtained through in-depth interviews to dig deeper into risky sexual behavior and HIV / AIDS prevention in MSM using thematic analysis.

Characteristics of Informants
The informants involved in the indepth interviews were ten people whom the researcher chose according to the research objectives, and they were varied. Seven informants are single, and three are married. Five informants are originally from Bali, and the other five are from outside Bali. Based on their educational background, seven informants are high school graduated, and the other three have graduated from junior high school. Their average monthly income is 1-3 million per month.

History of Same-Sex Relationships
The first sexual intercourse among MSM in Denpasar was mostly under the age of 20, at 14-15 years old, as the following informant admitted.

INTRODUCTION
Indonesia is the fifth developing country in Asia that has a high risk of HIV / AIDS. (1) HIV is a virus that causes AIDS that can lead to death. This virus attacks the human immune system and weakens the body's ability to fight any diseases. (2) HIV epidemic is a serious public health problem and challenge in both developed and developing countries. Male Sex Men (MSM) are at high risk of contracting HIV / AIDS. The prevalence of MSM in various countries varies widely; in 2008, in Mexico, it was 25.6%, Jamaica as much as 31.8%, in Bangkok, it was 28.3% in 2005. (3) (4) Since 2011, MSM cases in Indonesia have significantly increased from 5% to 8%. (5) Based on mathematical modeling of the HIV epidemic in Indonesia 2010-2025 using demographic, behavioral, and epidemiological data in the main population by The National AIDS Commission, it is projected that there will be a significant increase of HIV cases in all MSM groups. (6) The sexual behavior of MSM is classified as risky if it is engaging with anal sex without condoms and lubricants. (7) On the other hand, the epidemic in most industrialized countries has focused on MSM, besides, study conducted in sub-Saharan Africa has found evidence of a high HIV epidemic among MSM. However, the existence of MSM groups is like the iceberg phenomenon, which only a small part of it has managed to reach while others remain hidden and do not want to acknowledge themselves as MSM. (8) On the other hand, Bali is a province that is in the fifth place with the highest number of HIV and AIDS cases in Indonesia. As of October 2013, the proportion of AIDS cases among homosexuals in Bali province reached 336 cases. (9)  MSM who is married and has wive when having sex with his wive prefer to use condoms to prevent STIs and HIV / AIDS, as stated by the informant "KM 30 years".

HIV transmission prevention measures
Most of the informants used condoms during sexual intercourse to avoid HIV / AIDS. In addition, some informants used the PrEP or Pre-Exposure Prophylaxis method by taking ARVs regularly to prevent contracting HIV. The following is the informant's statements.

Consistency in using condoms during sexual intercourse
Most informants always use condoms when having sex with regular or non-permanent partners. They have a great knowledge regarding the function of condom. The following are the informant's statements.

Number of Sexual Partners
Some of the informants only have one permanent sexual partner. However, there are still MSM who have more than one partner and receive payment for sexual intercourse. The following is the statements from the informants.
" the MSM group prioritized variety and sensation to get sexual satisfaction. The informant will commit violence or get sexual violence to get a different sensation from the sexual relationship. The informants admitted that sexual violence perpetrated or obtained was physical violence such as beatings or ties to the body. Informants also obtained sexual satisfaction if they had repeated orgasms, for that the informant would use arousal-enhancing drugs. The arousal-enhancing drugs were also used when the respondent had sex parties with more than ten MSM members. Anal sex is a sexual activity performed by MSM to achieve sexual satisfaction and is very dangerous because the anus contains many disease-causing bacteria. The insertive partner will perform rimming (oral-anal) and fisting (inserting a finger or fist into the anus), which will cause injury and infection, leading to inflammation in the anus to satisfy the receptive partner. (12) In this study, some informants only have one permanent sexual partner. However, few MSM members have more than one partner and receive payment after doing sexual intercourse. The greater the number of sexual partners leads to random sex behavior, which will increase the infection-causing fatal diseases such as STIs and HIV. (13) A large number of sexual partners is also influenced by finding sexual partners using social media platforms. Having a regular partner does not ensure the possibility for MSM to have other sex partners. On average, each MSM has several sexual partners, and the courtship period is relatively less than one year. In addition, to feel more intimate in the relationship, the partner is called a girlfriend. On the other hand, having several sex partners among MSM can increase the possibility to have HIV infection. (14) There is no permanent gender role between an informant and his partner. Informants can be Top or Bottom. This condition can change according to the informant's pleasure during sexual intercourse to increase sensation. The insertive informants in this study admitted that they occasionally change positions as receptive to try There are still a few informants who only occasionally use condoms during sexual intercourse. It happens due to informant was lazy to buy condoms or the limited availability of condoms. However, if there was a condom, the informant always used it during intercourse. Informants rely only on condoms given by their partners. The following is the informant's statement.

DISCUSSION
This study found that MSM in Denpasar mostly had their first sexual intercourse while under 20 years, at the age of 14-15. Based on previous research, many adolescents reported starting sexual intercourse at an early age, when they were in high school, and 5.9% reported their first sexual intercourse before the age of 13 and having sex with older men. (10) Sexual desire at Adolescence mostly begins at the end of puberty at 13 years. In 2009, 27% of new HIV infection cases were from the young MSM cohort in the United States, and 69% of new HIV infections among people aged 13-29. (11) In this study, MSM argued that their reasons for having sex with the same sex were the temptation when their psychological condition was unstable. Since when they were a child experience a lack of love from their parents because their parents are busy working. Sexual intercourse under 16 years is highly discouraged because the reproductive organs have not yet experienced physical maturity. Therefore, it can harm health due to injuries that occur to the reproductive organs during sexual intercourse.
High-risk sexual intercourse behavior was obtained based on the consistency of condom use, the number of sexual partners, and the roles of informants during sexual intercourse. The in-depth interviews showed that in same-sex sexual relations, PrEP, appropriate health services, adequate and trained human resources required for a successful implementation of PrEP. The limitation of this study is that the researcher does not interview the pairs of informants involved.

CONCLUSION
As a sexual behavior, most MSM members prioritize variations and sensations during sexual intercourse to receive sexual satisfaction, such as having group sex, using arousal-enhancing drugs, and performing violence during sexual intercourse. Some of the informants only had one permanent sexual partner. However, there are still MSM who have more than one partner and receive payment for sexual intercourse. Most of the informants used condoms during sexual intercourse and the PrEP method to avoid HIV / AIDS. new sensations. Sexual roles between MSM members are not absolute, although some MSM members as often do not want to switch roles with their partners. In-depth interviews with informants showed that the sexual role of the MSM group is flexible, meaning that there is no special role for an MSM. The choice to be insertive or receptive is not based on body language but on what sexual sensations are wanted to achieve. An insertive informant admitted to having a receptive role if he did not have interest in his sexual partner but had to have sex because he received payment. (15) Most informants always use condoms when having sex with regular or nonpermanent partners since they have a great knowledge regarding the function of a condom. There are still a small number of informants who only occasionally use condoms during sexual intercourse. It was because the informant was lazy to buy condoms or the limited availability of condoms. On the other hand, MSM is a group with a high risk of contracting HIV, leading to AIDS. (16) Therefore, it is important to use condoms during sexual intercourse consistently. One of the factors of unprotected anal sex is MSM, who prioritize pleasure in sexual intercourse. In addition, MSM achieves more payment if they do not use a condom during sexual intercourse. (17) Most of the informants used condoms during sexual intercourse to avoid HIV / AIDS. Besides, some informants used the PrEP or Pre-Exposure Prophylaxis method by taking ARVs regularly to prevent transmission of HIV infection. PrEP is a combination of 2 ART (tenofovir and emtricitabine). This drug serves to prevent HIV transmission within people who have a high risk of contracting HIV. With the high number of new cases in Indonesia that continues to increase, PrEP can be a prevention strategy that can reduce the number of new cases of HIV transmission in Indonesia. (18) Even though PrEP has not been officially implemented in Indonesia, some people use PrEP. The implementation of PrEP in developing countries like Indonesia requires an appropriate strategy. A large budget is needed to bear the high cost of providing