Lay epidemiology and strategic ignorance in relation to HIV risk and testing: a qualitative study of the cultural practice of sifon in West Timor, Indonesia

A cultural practice following traditional male circumcision (TMC) in the Atoni Meto tribe, Indonesia, involves unprotected sex with unrelated women, such as widows or female sex workers (FSWs), known as sifon. This practice carries a high risk of transmission of HIV among men and sifon women. This study draws on in-depth interviews with 34 men from the tribe who had undergone TMC, and 12 healthcare professionals who engaged with young men from the tribe. Men who had engaged in sifon tended to have limited knowledge of HIV and its risks or of HIV testing. HIV testing was assumed to be necessary only on a doctor’s recommendation or for individuals with multiple unprotected sexual encounters with FSWs, though not for sifon purposes. Such lay understandings and lay epidemiology led participants to view themselves as non-candidates for HIV and thus not requiring HIV testing. Reliance upon and a valuing of tradition contributed to a gap between knowledge and practice on the HIV risks of sifon and HIV testing, even among Atoni Meto health professionals. Some were aware of the HIV risks associated with sifon but engaged in ‘strategic ignorance’ in understating the risk of transmission and avoiding stigma. Health professionals continued to face challenges in discussing the risks associated with sifon and promoting HIV testing due to their fears of community resistance. Understanding these community-shaped barriers to accessing HIV testing after sifon is critical for developing tailored interventions in order to increase awareness of the risks of HIV transmission through sifon practice.