ORIGINAL ARTICLE
Bali Medical Journal (Bali MedJ) 2025.
Volume 14.
Number 3 : 709-718 P-ISSN.
E-ISSN: 2302-2914
Risky sexual behaviour and PrEP acceptance for Human Immunodeficiency Virus Prevention:
a study amongst the general population at Badung Market Denpasar Luh Gede Pradnyawati1*.
Ni Ketut Sutiari2.
Luh Seri Ani2.
Pande Putu Januraga3
ABSTRACT
Department of Public Health and Preventive Medicine.
Faculty of Medicine and Health Sciences.
Warmadewa University.
Indonesia Department of Community and Preventive Medicine.
Faculty of Medicine.
Udayana University.
Indonesia Centre for Public Health Innovation.
Udayana University.
Indonesia *Corresponding author:
Luh Gede Pradnyawati.
Department of Public Health and Preventive Medicine.
Faculty of Medicine and Health Sciences.
Warmadewa University.
Indonesia.
pradnyawati@warmadewa.
Received: 2025-09-05 Accepted: 2025-11-14 Published: 2025-12-17 Introduction: Human Immunodeficiency Virus (HIV) is a virus that weakens the bodyAos immune system and causes multisystemic disease.
HIV infection results in significant morbidity and mortality for those affected.
Furthermore, individuals with HIV must take medication for life to control the disease.
Therefore.
HIV prevention is paramount.
Pre-exposure prophylaxis (PrEP) is an HIV prevention intervention using antiretroviral medication.
Beyond key populations, other general populations are at risk due to unsafe sexual behaviour, namely market traders and housewives, who are also vulnerable to HIV infection.
Methods: This study employed a purely qualitative design to examine risky sexual behaviour and PrEP acceptance for HIV prevention amongst at-risk general populations at Badung Market.
Denpasar City.
The research involved 25 informants comprising traders, trader coordinators, market unit heads, primary health centres, and the Denpasar City Health Office.
The study utilised thematic data analysis.
Results: The prevalence of multipartner sexual behaviour amongst Badung Market traders, both married and unmarried, was notable.
This behaviour significantly increases the risk of sexually transmitted infection (STI) and HIV transmission, particularly when combined with inconsistent condom use.
Interview analysis revealed that over 90% of trader informants had never heard of PrEP before this research interview.
There was high acceptance of the mobile PrEP service model at Badung Market due to ease of access.
Simultaneous implementation of Level 1 Ae Predisposing: Changing Knowledge.
Attitudes, and Perceptions.
Level 2 Ae Enabling: Facilitating Access.
and Level 3 Ae Reinforcing: Creating Social Support is predicted to increase PrEP uptake, ensure adherence, and ultimately reduce HIV incidence in the market trader population.
Conclusion: The Badung Market trader population is at high risk of HIV due to multipartner sexual behaviour and inconsistent condom use.
Despite minimal knowledge about PrEP, they demonstrate good acceptance of mobile PrEP services.
Prevention programmes must focus on education and integrated access improvement to achieve effective HIV incidence reduction.
Keywords: Risky Sexual Behaviour.
PrEP Acceptance.
HIV Prevention.
Badung Market.
Cite This Article: Pradnyawati.
Sutiari.
Ani.
Januraga.
Risky sexual behaviour and PrEP acceptance for Human Immunodeficiency Virus Prevention: a study amongst the general population at Badung Market Denpasar.
Bali Medical Journal 14.
: 709-718.
DOI: 10.
15562/bmj.
INTRODUCTION
Human Immunodeficiency Virus (HIV) is a virus that weakens the bodyAos immune system and causes a multisystemic disease called Acquired Immune Deficiency Syndrome (AIDS).
The first case of HIV was reported in Los Angeles.
United States, in 1981.
1 Since the beginning of the epidemic, an estimated 85.
6 million people have been infected with HIV, and 4 million have died from HIV.
Globally, approximately 39 million people were living with HIV at the end of 2022.
The prevalence of adults aged 15Ae49 years worldwide living with HIV is estimated HIV prevalence is higher in low- and middle-income countries than in developed nations.
In 2022, there were 630,000 HIV-related deaths and 1.
million new HIV cases.
Open Bali Medical Journal 14.
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HIV infection causes significant morbidity and mortality for those affected.
Furthermore, individuals with HIV must take medication for life to control the Therefore.
HIV prevention is In 2015, the World Health Organization (WHO) recommended Pre-Exposure Prophylaxis (PrEP) as an additional prevention option for people at high risk of HIV infection who are ORIGINAL ARTICLE still HIV-negative.
3 PrEP has been shown to be 99% effective in preventing HIV transmission from sexual contact and 74% effective from injection drug use.
PrEP medication has also been proven safe for human consumption based on clinical 4,5 According to Minister of Health Regulation Number 23 of 2022 concerning the control of HIV.
AIDS, and STIs.
Article 18 states that ARV prophylaxis is provided to people at risk of HIV, both those already exposed to HIV and those not yet Bali Province is the province with the sixth-highest number of HIV cases and fifth-highest AIDS cases based on data and reports from the Indonesian Ministry of Health from 2010 to March 2023.
people were living with HIV, and 11.
AIDS cases were found in Bali Province from 1987 to March 2023.
7 The number of HIV-AIDS cases reported to the Bali Provincial Health Office continued to increase yearly from 2016 to 2022.
2020, there were 7.
189 HIV cases in Bali Province.
HIV cases in Bali Province were dominated by males at 68.
16% and the 2549 age group at 67.
Approximately 40% of these cases were reported by the Denpasar City Health Office, whilst 60% came from 8 districts in Bali.
The number of female cases was lower than male cases, but the increase pattern was similar to that of male cases.
Pre-exposure prophylaxis or PrEP is an HIV prevention intervention using antiretroviral (ARV) medication.
PrEP should not replace or compete with effective and established HIV prevention interventions such as comprehensive condom programmes for sex workers and men who have sex with men or injection drug users.
Currently, many people who would benefit most from PrEP are within key population groups who may face legal and social barriers to accessing health Beyond key populations, other general populations are at risk due to unsafe sexual behaviour, namely market traders and housewives, who are also vulnerable to STIs and HIV-AIDS infection, according to a study conducted by Pradnyawati at Badung Market.
Denpasar City.
10 One place in Bali with high social interaction is the market.
In Bali ProvinceAos capital.
Denpasar, there is Badung Market, which is the largest traditional market and the economic centre of Denpasar City and its surroundings, operating 24 hours.
Badung Market is located on Gajah Mada Street, the main thoroughfare that serves as the shopping centre of Bali ProvinceAos capital.
Badung Market has transformed into a space for social interaction between locals and migrants.
Most traders at Badung Market have low education levels and are far from their partners due to their busy schedule, earning money to support their families.
Additionally, most traders come from outside Denpasar, whilst their families remain outside Denpasar.
Low education and separation from partners are risk factors for risky sexual relationships, such as multiple partners and unprotected sex.
This creates an HIV risk for female traders at Badung Market.
METHODS
Study design This study employed a purely qualitative design to examine risky sexual behaviour and PrEP acceptance for HIV prevention amongst at-risk general populations at Badung Market.
Denpasar City.
In the qualitative research, in-depth interviews were conducted with traders, market stakeholders, and trader coordinators using the PRECEDE model and Health Belief Model behavioural theory.
The objectives of this qualitative research were to explore the context of sexual behaviour and HIV risk amongst Badung Market traders, including risky behaviour patterns, risk perceptions, and factors influencing behaviour.
Also, analyse barriers to and facilitators of PrEP uptake amongst market traders using the Health Belief Model (HBM) framework, evaluate acceptance of the mobile PrEP service model, including operational preferences .
iming, location, service forma.
and prerequisites for successful implementation, and integrate qualitative findings with the HBM and PRECEDE theoretical frameworks, presenting crosstheme synthesis and implications for intervention design.
The interviews were conducted by a faculty member from the Faculty of Medicine and Health Sciences.
Warmadewa University, who is currently pursuing a doctoral degree in Public Health with a focus on reproductive health and HIV The interviewer.
Dr.
Luh Gede Pradnyawati.
Kes, is a medical doctor and serves as the Head of the Department of Public Health and Preventive Medicine.
She is a female researcher with extensive experience in qualitative interviewing, having received formal training in 2014 at Yayasan Kerti Praja.
She has been actively involved in reproductive health and HIV prevention research since 2014, including long-term engagement with the Badung Market community.
Participants were aware of her dual role as both a doctor and The interviewer maintained reflexivity by acknowledging her position, prior familiarity with the setting, and potential biases related to her professional background, ensuring a neutral stance during data collection.
Data collection procedures The research involved 25 informants comprising traders, trader coordinators, market unit heads, primary health centres, and the Denpasar City Health Office.
Trader informants were recruited from each block .
ast block, middle block, west bloc.
and during different trading times .
orning, afternoon, evening, and dawn traders, both male and femal.
at Badung Market.
After all preparations were complete, researchers conducted in-depth interviews with informants who met the criteria, with a duration of 60-90 minutes per informant.
Participants were approached through direct face-to-face engagement and invited to participate in an in-depth interview conducted in a private, comfortable room within the Badung Market area.
The interviews were undertaken strictly in a one-on-one setting, without the presence of any third parties to ensure confidentiality and comfort.
ThereAos no dropout participants.
The interview guide was developed explicitly for the market setting, community-based in nature, and grounded in the Health Belief Model and PRECEDE framework.
Interviews were conducted once per participant .
o repeat interview.
, and all interviews were audio-recorded with consent.
Field notes Bali Medical Journal 2025.
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ORIGINAL ARTICLE
were systematically taken during and after each interview to capture contextual The duration of each interview was approximately 1 hour and 30 minutes per informant.
Table 1.
Data analysis This study employed thematic analysis.
The first stage involved compiling transcripts from the in-depth interviews.
Next, coding was performed.
Coding is the process of breaking down data into smaller, meaningful units.
Subsequently, categories were created from these smaller Interview transcripts were re-read for recoding.
After recoding, information categories were created by grouping similar information from the coding, and each category was analysed based on research All transcripts were organised and analysed using NVivo version 20 qualitative data management software to facilitate systematic coding and theme Finally, interpretation of the information was conducted, creating detailed analytical descriptions of participantsAo feelings, opinions, and perceptions contained within the themes.
Demographic characteristics of trader, assistant, and market staff informants .
Characteristics At-risk Trader/Assistant/Labourer Non-at-risk Trader Trader Coordinator Male Female 20-29 years 30-39 years 40-49 years Informant Category Gender Age Group Mean age (SD) 4 .
years Age range 22-45 years Education Level Primary School Junior Secondary School Senior Secondary School Undergraduate Degree Within Denpasar City RESULTS Outside Denpasar City (Bal.
Characteristics of the study subjects This qualitative study involved 25 informants selected purposively to represent various perspectives regarding the development of a mobile PrEP service model at Badung Market.
Informants consisted of 18 traders, trading assistants, trading labourers, and market staff who constituted the target population for the intervention, as well as 7 key stakeholders, including market management, primary health centre staff, and the health office, who play roles in implementing health programmes in the market environment (Table .
Stakeholder involvement from various levels .
arket management, primary health centres, and health offic.
in this study is essential for understanding health system and market management perspectives regarding feasibility, barriers, and support required for mobile PrEP service implementation in Table 2.
Outside Bali Province Owner/Trader Trading Assistant Trading Labourer Market Staff Trader Coordinator Region of Origin Employment Position Note: Some informants had dual roles .
, trader and coordinator simultaneousl.
Table 2.
Stakeholder informants .
No.
Category Institution/Position Market Management Head of Human Resources of Perumda Pasar Sewakadarma Market Management Head of Badung Market Unit Market Management Head of Kumbasari Market Unit Primary Health Centre Denpasar Barat 2 Primary Health Centre Primary Health Centre Denpasar Utara 1 Primary Health Centre Primary Health Centre Denpasar Utara 3 Primary Health Centre Health Office Denpasar City Health Office Bali Medical Journal 2025.
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Sexual behaviour and HIV risk amongst market traders, including multipartner patterns, inconsistent condom use, and STI history Most behaviour revealed they had their first sexual experience at a relatively young age, between 16 and 20 years, before marriage or in a dating context.
Young sexual debut age is one indicator of vulnerability to risky sexual behaviour later in life, due to a lack of knowledge about reproductive health and STI/HIV prevention at that age.
AuThe first time I had sex was at age 16.
At that time.
I had just finished junior high school.
This girl was my neighbour.
Ay (NDM, 25 years, vegetable trading assistant, mal.
Informants reporting risky behaviour revealed they remained sexually active with varying frequency, depending on opportunities and context.
Some unmarried informants reported having sexual intercourse with girlfriends when opportunities arose to meet, whilst married informants reported varying frequency of sexual intercourse with legal partners, often hindered by work-related AuWith my girlfriend, there was once a month ago when I went home to Blitar.
How many times in a month? About 5 Ay (NDM, 25 years, male, trading However, interestingly, whilst some informants reported rarely having sexual intercourse with legal partners due to fatigue, they remained engaged in sexual relations with other partners outside This indicates that fatigue is not the sole factor influencing sexual activity, but emotional factors and opportunities also drive risky behaviour.
AuRarely do I have sex because my husband likes to play around with So.
IAom not bothered either.
Ay (NKP.
Trading Assistant, 30 years.
Femal.
The most significant finding from this study is the prevalence of multipartner behaviour amongst Badung Market traders, both married and unmarried.
the 9 informants reporting risky behaviour, most revealed having more than one sexual partner, either simultaneously or alternately, within a specific time period.
This behaviour significantly increases STI and HIV transmission risk, particularly when combined with inconsistent condom AuBut I have another partnerA and I had sex 3 days ago.
Hehehe.
Ay (NDM, 25 years, male, trading assistant Ae admitted having a girlfriend in Blitar and another partner in Denpasa.
The trader coordinator informant with in-depth knowledge of social dynamics in the market confirmed that infidelity and multi-partner behaviour are relatively common phenomena in the market environment, although conducted AuMany here who are married have In my opinion, [PrEP] is beneficial, especially at the market where there are indeed issues of infidelity amongst traders.
Ay (F, 32 years, trader coordinator, femal.
Confirmation from various informants indicates that the issue of infidelity is not merely an assumption or stigma, but a social reality acknowledged by traders Interview analysis revealed this pattern.
Reasons and Motivations for Multi-partner Behaviour Interview analysis primary reasons:
Emotional Needs and Communication AuAbut at home sheAos busy with the My communication with my wife isnAot excellent.
Sometimes my wife nags for no reason.
I donAot feel comfortable at home.
When we argue, my mother usually intervenesAAy (IWJP.
Trader, 34 years.
Mal.
Physical Attraction AuHow shall I put itA IAove already fallen for herA SheAos prettyA good bodyAAy (DP.
Trader, 26 years.
Mal.
Occupational Monotony AuAmy job is security, just sitting at the security post, sometimes walking around checking the situation at the Sometimes itAos boring, what to Tedious too.
So.
I chat online.
Meet girls on social media.
Basically, so that IAom not bored at work.
Ay (IKYD.
Security, 22 years, mal.
Childlessness (Social Pressur.
AuAmy wife is a hotel employee, has to work shifts.
Sometimes morning, afternoon, evening.
So, we rarely meet.
I donAot have children yet.
Been married 3 yearsAAy (IDGPA.
Trader, 29 years.
Economic Opportunity (Transactiona.
AuThis third one is married.
I donAot really like her, actually.
But sheAos wealthy, she often gives me money after we have sexAAy (IPA.
Trader, 36 years, mal.
Analysis of causes of risky behaviour indicates that multi-partner phenomena are multifactorial, involving psychological .
motional needs, boredo.
, social .
ermissive biological .
hysical attractio.
, and economic .
These findings are consistent with the PRECEDE Model Ae Predisposing Factors, where attitudes, values, and beliefs influence health behaviour.
Knowledge and perceptions about PrEP reveal very low awareness, critical misconceptions, and strong Limited Knowledge Among Traders Interview analysis revealed that over 90% of trader informants had never heard of PrEP before this research interview.
When asked whether they were familiar with the term AuPrEPAy.
AuPre-Exposure ProphylaxisAy, or the concept of Aumedication to prevent HIVAy, the most common response showed confusion and complete unfamiliarity with the idea.
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AuWhatAos thatA IAove never heard of itA Is it a pill?Ay (NDM, 25 years, vegetable trading assistant, mal.
AuNever heard of it.
Ay (NKP, 30 years, trading assistant, femal.
Implementation Gap at Health System Level More significantly, the knowledge gap about PrEP exists not only amongst traders but is also reflected in limited PrEP implementation for the general Whilst Health Office informants demonstrated awareness of PrEP availability, they acknowledged implementation remains very limited:
AuPrEP services are available, facilitated by the health office and Ministry of Health.
There is a PrEP budget for atrisk populations.
Ay (YA.
Field officer, 29 years, femal.
Misconception 1: PrEP for People Already Infected with HIV The most critical misconception that emerged is confusion between PrEP .
rophylaxis for healthy peopl.
and ART .
reatment for people living with HIV).
Several informants perceived PrEP as a medication for people already infected with HIV:
AuPrEP is an ARV medication given to someone not infected with HIV, before being exposed to HIV.
Ay (GAKSW.
Programme Manager, 54 years.
Femal.
Whilst technically correct, this statement reflects conceptual ambiguity common in the field, because use of the term ARV is often associated with therapy for people already HIV-positive, this reinforces public misunderstanding that PrEP users are infected individuals.
Misconception 2: PrEP Supports Risky Behaviour A second misconception that emerged, particularly from stakeholder informants, is the concern that PrEP would encourage risky sexual behaviour because users feel protected from HIV:
AuBut if thereAos such medication, itAos easy for themA They can change partners more oftenA More freedom to experimentAAy (DNMF.
Trader, 31 years.
Femal.
Misconception 3: PrEP Only for Key Populations The third and most significant misconception is the association of PrEP with key populations such as commercial sex workers or men who have sex with AuCurrently there is no PrEP programme for the general public, only for certain population groups (MSM, transgender, injecting drug users, partners of people living with HIV).
Ay (LGWK.
Midwife, 37 years.
Femal.
Barriers to and facilitators of PrEP uptake using HBM and PRECEDE frameworks, identifying fear of side effects and stigma as significant barriers, and authority support and peer support as the strongest Fear of Side Effects as Dominant Barrier: More Than Medical Concerns When traders were asked about their concerns regarding PrEP, the most frequent and most substantial response was fear of side effects.
However, in-depth analysis revealed this fear is not merely a rational medical concern but reflects deeper psychological complexities about tradersAo relationship with medication, the body, and risk.
AuIn my opinion.
IAom worried about side It must be strong medication.
IAom afraid of getting sick, not being able to Ay (NNA.
Trader, 43 years, femal.
Authority Support as Legitimisation and Destigmatisation One of the most consistent and strong findings is that support from authorities .
overnment, market management, health offic.
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AuHmmA IAom still hesitant about taking itA Because the medication is still newA havenAot seen the evidenceA But if itAos officially a government programme.
IAom willing.
Ay (NWR.
Trader, 45 years.
Femal.
Acceptance of the mobile PrEP service model, revealing very high support from traders with specific operational High Acceptance Due to Ease of Access Almost all trader informants demonstrated firm support for the mobile PrEP service concept, with the primary reason being ease of access that overcomes barriers of busy schedules and distance.
AuThatAos excellentA Traders donAot have to go far for treatmentA thereAos a clinic inside the marketA Traders find it easy to check their healthAAy (NKP.
Trading assistant, 30 years, femal.
Analysis revealed strong support patterns for the mobile clinic model.
The consistency of these findings across various informants indicates that mobile services have high acceptability amongst market traders.
Perceived Benefits of Mobile Clinic Informants could identify various specific benefits of mobile clinic services, not only for PrEP but also for general health AuSomething like this is goodA Having a clinic inside the marketA This kind of service is excellent and beneficialAAy (NKP.
Trading assistant, 30 years.
These findings indicate that traders not only passively accept mobile services but can see the value and relevance of such services for their health needs.
This is important because it shows acceptance is not merely due to Auno other choiceAy, but because of genuine appreciation for a service model that suits their context.
ORIGINAL ARTICLE
Table 3.
Synthesis of health belief model constructs.
HBM Construct Status Primary Findings Intervention Implications Perceived susceptibility Very low Traders do not perceive themselves at risk of HIV infection despite consider HIV only affects Auspecific populationsAy (CSW.
MSM), resulting in psychological distancing.
Highest priority: strengthen risk awareness through self-risk assessment, individual counselling, and reframing that anyone with an unfaithful partner is at risk of HIV exposure Perceived severity High HIV is perceived as a fatal disease with severe social stigma.
the fear of the disease is already elevated Education must emphasise that HIV is preventable.
high severity should be channelled into motivation for PrEP protection.
Perceived benefits Ambiguous PrEP benefits are acknowledged for AuothersAy but not for oneself.
and psychological benefits emerge following education.
Contextualise personal benefits using testimonial narratives and peer support.
Perceived barriers Very high Fear of side effects .
ost frequently cite.
, social stigma, perception of not requiring it due to feeling healthy, and scepticism towards new medication Education on PrEP safety, social proof from early adopters, and confidential service design Cues to action Absent Minimal exposure to PrEP information.
no proactive HIV testing programme.
absence of personal triggers Create triggers through visual campaigns, routine sensitisation, mobile services, and authority Self-efficacy Low Lacking confidence in adhering to the PrEP regimen, feeling unready to Enhance self-confidence through education, peer support, and health worker accompaniment.
Advantages of Mobile Service Model:
Multi-Dimensional Analysis Close Access and Non-Disruptive to Trading Mobile services eliminate geographical barriers as the clinic is placed within the market.
Traders do not have to leave their stalls or incur transportation costs to reach the primary health centre.
This convenience is crucial for traders who depend on daily income and cannot leave their goods for too long.
AuVery good in my opinion, so itAos close to us.
Traders are busy.
So before going home, we can stop by the clinic firstA the only drawback might be feeling embarrassed about coming to the clinic.
If possible, it should be kept confidential that there will be PrEP medication Ay (KD Ae trading labourer, 45 Integration of qualitative findings with HBM and PRECEDE theoretical frameworks, presenting cross-theme synthesis and implications for intervention design Synthesis of Health Belief Model Constructs Table 3 summarises cross-theme findings according to HBM constructs.
The status of each construct is based on market tradersAo perceptions and interpreted within the HBM framework.
The AuImplicationsAy column depicts relevant intervention The Severity Paradox vs.
Susceptibility Cross-theme fundamental paradox: market traders view HIV as a deadly disease .
igh severit.
but do not feel vulnerable .
ow susceptibilit.
In HBM literature, perceived susceptibility proves to be a stronger predictor of preventive behaviour than perceived Early meta-analyses found that perceived barriers are the strongest predictor of preventive behaviour, whilst perceived severity is the weakest.
susceptibility and perceived benefits lie in The situation of market traders aligns with these findings: high fear of HIV does not translate into action because they do not feel personally threatened.
This paradox creates cognitive dissonance: to reconcile fear of HIV with the belief that one is not at risk, traders engage in psychological distancing, positioning HIV as someone elseAos problem.
This condition hinders informationseeking and PrEP acceptance.
Intervention focus must raise perceived susceptibility through personalised risk assessment, so that high severity can become motivation to act rather than to avoid.
Interaction of Benefits and Barriers Findings indicate that barriers dominate Even after traders learn about PrEPAos clinical benefits, fear of side effects and social stigma still block the Bali Medical Journal 2025.
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Table 4.
Synthesis of PRECEDE factors: multi-level barriers.
Level Predisposing Enabling Reinforcing Factor Status Primary Findings Intervention Knowledge Very low >90% of traders have never heard of PrEP.
limited HIV knowledge, with many misconceptions Comprehensive multi-channel education.
self-risk assessment sessions Attitudes Ambiguous Positive attitude towards PrEP but Aunot for meAy.
fatalism towards HIV Reframing through risk contextualisation and testimonials Perceptions Paradoxical High perceived severity but low susceptibility.
benefits, high barriers Increase Service access Limited PrEP is only targeted at key tradersAo schedules hinder access.
Mobile services Resources Limited A PrEP budget exists, but for key populations, the mobile service budget is unavailable.
Specific budget allocation: mobile service pilot project Skills Lacking Traders lack self-assessment health workers need capacity building.
Training for health workers and trader Social support Absent No peers using PrEP yet.
Formation of support groups.
Authority support Potentially Traders are willing to follow if recommended by the government and market management.
Involvement of health authorities and market management in campaigns Reinforcement Negative Stigma used as punishment.
information spreads quickly in the market Destigmatisation through services and anonymisation adoption possibility.
HBM meta-analysis confirms that perceived barriers are often the strongest predictor of preventive Therefore, intervention must focus on barrier reduction .
, education about PrEP safety, use of pilot cases, and services with high confidentialit.
alongside increasing personal benefits.
Absence of Cues to Action Amongst market traders, there are almost no cues to action that trigger PrEP information-seeking.
According to HBM, cues to action serve as necessary triggers to activate motivation.
However, if perceived susceptibility is low, a single trigger may not be effective.
Therefore, campaigns must be designed to increase risk perception whilst simultaneously providing action triggers such as outreach government/market management support.
Synthesis of PRECEDE Factors:
Multi-Level Barriers The PRECEDE model emphasises that health behaviour is influenced by three categories of factors: predisposing .
nowledge, attitudes, belief.
, enabling .
esource availability and acces.
, and reinforcing .
ocial and institutional Recent empirical reviews in epidemic prevention contexts confirm that predisposing attitudes such as perceived vulnerability drive preventive action.
reinforcing factors such as institutional support maintain long-term adherence.
and enabling factors such as service access and training facilitate translation of intention into practice.
The following table summarises PRECEDE factors identified from qualitative research and their status amongst market traders in Table 4.
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Multi-Level Interaction Qualitative findings indicate that barriers at one level reinforce barriers at other levels, creating a cycle of obstacles.
For instance, low knowledge .
reduces perceived susceptibility, so traders do not feel the need to seek PrEP.
limited-service access .
makes PrEP difficult to obtain even when motivation exists.
and absence of social proof .
strengthens stigma and reduces motivation.
PRECEDE learning documents emphasise that this model combines individual-level, community, media, and grassroots movement theories so that intervention can proceed at various levels simultaneously.
PROCEED
was added to highlight the importance of environmental and policy factors in health determinants.
Therefore, single interventions targeting only individual knowledge will not succeed without ORIGINAL ARTICLE environmental .
ervice acces.
and social .
eer/authority suppor.
Integration Model: From Theory to Practice Based on HBM and PRECEDE synthesis, an integrative model for developing mobile PrEP services amongst market traders can be formulated as follows:
Level 1 Ae predisposing: changing knowledge, attitudes, and perceptions, such as: input: Comprehensive multichannel education, self-risk assessment, individual counselling, testimonials, also process: Address misconceptions, increase perceived susceptibility, emphasise PrEP benefits, and reduce fear of side effects, and output: Increased risk awareness, personal benefits understood, psychological barriers reduced, and self-efficacy increased.
Level 2 Ae enabling: facilitating access, such as:
Input: Mobile services at market, policy advocacy, budget allocation, staff training, also process: Provide easily accessible, safe, and private services.
with other health services.
removal of restrictive requirements, and output: PrEP access available and accepted, practical and policy barriers reduced.
Level 3 Ae reinforcing: creating social support, such as: input: peer support, authority support, destigmatisation, public communication campaigns, also process: Build social proof through champions, shift negative reinforcement to positive, equate PrEP narrative as a general protection choice, and output: Strong social support, reduced stigma.
PrEP uptake becomes a social
DISCUSSION
Analysis of sexual behaviour amongst Badung Market traders reveals a finding that challenges conventional assumptions about HIV risk distribution: 50% of interviewed traders reported highrisk sexual behaviourAia prevalence comparable to or even exceeding some HIV key populations.
However, market traders are not included in the key population category in conventional classification and therefore are not targeted by existing HIV prevention programmes.
This reveals a blind spot in the HIV prevention paradigm that focuses only on epidemiologically defined key populations, whilst ignoring general populations in specific social contexts who are equally at risk but remain What makes this finding more concerning is that risky behaviour at Badung Market is not an individual anomaly but a structural phenomenon facilitated by the marketAos social ecosystem Traditional markets, with high proximity dynamics, unstructured leisure time, and gender imbalance, create conditions conducive to multipartner Furthermore, this risky behaviour is normalised within specific sub-groups, creating an environment where health risks are not perceived as risks but as part of daily life.
This aligns with research conducted by Pradnyawati in 2019 at Badung Market.
Denpasar City.
As many as 22% of respondents admitted that they had sexual intercourse with more than one partner over the last year, with 41% of them using a condom during their last sexual In-depth interviews revealed that the basis of their sexual intercourse was mutual interest and desire.
Only one respondent admitted economic reasons for sexual intercourse.
Condoms were rarely used because of the low-risk perception of sexual intercourse.
Prevention programmes targeting low-risk groups are required to reduce the burden of disease from STIs, including HIV.
Regarding risks and potential STI and HIV incidents amongst women from general populations, research on womenAos vulnerability to STI and HIV transmission was conducted at three service locations in Denpasar, one of which was at the YRS Reproductive Health Clinic in Badung Market.
This qualitative research used the in-depth interview method with a semi-structured interview guide on 21 informants, consisting of female informants, male informants, counsellors, and health service providers.
The results of this research indicate that risky behaviour causing womenAos vulnerability to STI and HIV transmission is partner sexual behaviour with more than one partner, low bargaining position in condom negotiation, prostitution, and forced sexual intercourse.
Interview analysis revealed that over 90% of trader informants had never heard of PrEP before this research When asked whether they were familiar with the term AuPrEPAy.
AuPreExposure ProphylaxisAy, or the concept of Aumedication to prevent HIVAy, the most common response showed confusion and complete unfamiliarity with the idea.
The Indonesian government, since 2021, has launched a project to distribute PrEP free of charge to key populations in 7 provinces.
During 2022, the PrEP programme was implemented in 21 districts/cities in 10 provinces as a limited trial for MSM and sex worker populations.
Unfortunately.
PrEP implementation still has low adherence rates.
of 2,794 MSM and sex worker clients who started, only 14 people remained in the programme at month twelve.
PrEP coverage is also still low, only 19% in the MSM population and 12% in the sex worker population.
PrEP can be prescribed to individuals who have HIV-positive sexual partners, engage in anal or vaginal sex within 6 months without condoms, have been diagnosed with a sexually transmitted infection (STI) in the past 6 months, are injection drug users, or use needles.
Currently, there are two types of medication approved for PrEPAiTruvadaA .
mtricitabine/tenofovir disoproxil fumarat.
for all people at risk of contracting HIV through sexual intercourse or injection drug use, as well as DescovyA .
mtricitabine/tenofovir alafenamid.
for men and transgender women who are sexually active and at risk of contracting HIV.
12,13
Pre-exposure prophylaxis is intended for people who engage in high-risk sexual behaviour and do not use condoms PrEP use is widely promoted in MSM communities, including MSM who wish to practise safer sex in sexual relationships with casual partners, where it is challenging to share HIV and STI status with such sexual partners.
The use of PrEP as prevention has been working well, as seen in hook-up application messages .
ersonal communication by user.
displaying PrEP use status.
14,15
PrEP has proven to be a safe and highly effective HIV prevention method for MSM, people who inject drugs (PWID), and heterosexual men and women.
PrEP allows implementation as an HIV transmission prevention intervention for Bali Medical Journal 2025.
: 709-718 | doi: 10.
15562/bmj.
ORIGINAL ARTICLE
people at high risk of HIV infection during regular use.
Moreover, oral medication still feels more private than other HIV prevention methods.
16 According to the latest WHO data, based on research by Eisingerich in 2012.
PrEP is more likely to be used for key populations at risk of HIV infection.
If affordable treatment access were made available, this drug could be successful in suppressing HIV 17 PradnyawatiAos 2020 research, which conducted in-depth interviews with 10 MSM in Denpasar City, showed that the PrEP method is one way to avoid HIV.
The latest WHO data shows that long-acting Lenacapavir (LEN) as PrEP is highly effective in preventing HIV transmission in women.
This is a significant breakthrough in HIV prevention.
Complete results of the PURPOSE 1 trial, presented at the 25th International AIDS Conference, demonstrate the safety and efficacy of the long-acting injectable antiretroviral drug LEN for PrEP in HIV-negative cisgender LEN is an HIV-1 capsid inhibitor administered via subcutaneous injection twice yearly for HIV prevention.
LEN has the potential to increase further the reach of effective and acceptable prevention options for women, addressing challenges, including those associated with effective oral tablet use and growing acceptance and use of prevention.
AuOn-demandAy PrEP is a dosing strategy where someone takes oral PrEP only around the time of sexual activity .
aken before sexual intercours.
and is based on the ability to plan sexual activity.
A randomised, double-blind, placebocontrolled trial in France and Canada amongst MSM evaluated a double-dose protocol .
tablets taken togethe.
of oral TDF-FTC .
r placeb.
between two and 24 hours before sexual activity and then single TDF-FTC tablets at 24 hours and 48 hours after the first dose with continued daily dosing if exposure continues.
Participants randomised to active TDFFTC showed an 86% reduction in HIV infection incidence compared with those randomised to placebo.
Notably, the average number of doses was 15 tablets per month, approaching the 4 doses per week known to provide high-level rectal protection during daily dosing attempts.
Post-hoc subgroup analysis showed that on-demand PrEP remained effective in participants with less frequent sexual Current guidelines for ondemand dosing remain contradictory, and pharmacokinetic data offer conflicting predictions about on-demand dosing efficacy due to a lack of clarity regarding optimal pharmacokinetic correlates for HIV protection.
20,21
Analysis of PrEP acceptance amongst Badung Market traders reveals a complex paradox: on one hand, there is recognition of PrEPAos potential benefits when explained.
on the other hand, there is strong resistance to personal adoption.
This paradox is not merely a matter of Auknowing but unwillingAy, but reflects dynamic interaction amongst various psychological, social, and structural factors that mutually reinforce one another.
However, in implementation, there are several barriers to PrEP use in society, including still low PrEP use even though this programme has been promoted by the government as HIV prevention.
Additionally, awareness of PrEP use remains low, incorrect information about PrEP eligibility still circulates in society, concerns about PrEP side effects.
PrEP costs, stigma about consuming PrEP, and medical distrust towards PrEP use.
Inadequate adherence to consuming PrEP can cause decreased PrEP efficacy.
This aligns with research findings showing that PrEP acceptance cannot be understood as a linear spectrum from AurejectingAy to AuacceptingAy but is more appropriately understood as a force field where barriers and facilitators precarious condition.
Traders may demonstrate openness to PrEP in one moment, yet immediately retreat when faced with questions about whether they themselves would use it.
This instability reveals that psychosocial barriers are more dominant than informational barriersAi the problem is not that traders donAot know about PrEP .
ecause indeed the majority donAot know ye.
, but that when they do know, other barriers immediately emerge to block adoption.
Simultaneous implementation at all three levelsAiLevel 1AiPredisposing:
Changing Knowledge.
Attitudes, and Bali Medical Journal 2025.
: 709-718 | doi: 10.
15562/bmj.
Perceptions.
Level 2 Ae Enabling: Facilitating Access.
and Level 3 Ae Reinforcing:
Creating Social SupportAiis predicted to increase PrEP uptake, ensure adherence, and ultimately reduce HIV incidence in the market trader population.
This multilevel approach aligns with PRECEDEPROCEED principles that combine interventions at individual, environmental, and policy levels.
By addressing the cycle of barriers comprehensively, this model offers a theory- and data-based strategic plan for PrEP intervention in Indonesian traditional markets.
CONCLUSION
Multi-partner sexual behaviour among Badung Market tradersAiboth married and unmarriedAiremains a significant Among the nine informants reporting risky practices, most engaged in simultaneous or sequential multiple partnerships, elevating the risk of STI and HIV transmission, especially with inconsistent condom use.
More than 90% of informants had never heard of PrEP before the interview, yet showed strong acceptance of a mobile PrEP service due to its accessibility.
Implementing Level 1 .
Level 2 .
, and Level 3 .
interventions simultaneously is expected to strengthen PrEP uptake, adherence, and overall HIV This multi-level strategy aligns with PRECEDE-PROCEED principles and provides a practical, evidence-based framework for PrEP implementation in traditional market settings.
ACKNOWLEDGEMENTS
The researchers thank all participants involved, both directly and indirectly.
AUTHORS CONTRIBUTION
All authors contributed substantially to the completion of this study.
conceptualised the study, developed the research framework, and coordinated the overall study design together with Data collection and processing were carried out by L.
, and The analysis and interpretation of the qualitative data were conducted collaboratively by L.
and N.
, and L.
the literature search.
All authors were ORIGINAL ARTICLE actively involved in drafting, reviewing, and finalising the manuscript, with L.
, and L.
contributing to the writing and critical revision of all sections.
All authors approved the final version of the manuscript.
CONFLICT OF INTEREST
All the authors declare that there are no conflicts of interest.
ETHICAL CONSIDERATION
This study received ethical approval under reference number 1967/UN14.
VII.
LT/2025, issued on July 27th, 2025, by the Research Ethics Committee.
All participants provided informed consent prior to data collection, and confidentiality was maintained throughout the study in accordance with established ethical FUNDING None.
REFERENCES