The acquired immunodeficiency syndrome (AIDS) case rate is increasing in Indonesia, especially in Papua and West Papua Provinces. As of September 2011, Papua's AIDS case rate was the highest among all 33 provinces in Indonesia, at 180.7/100,000 population, which was 16.3 times higher than the national rate of 11.1/100,000 population. The second highest rate was in West Papua at 51.5/100,000 population. Even more alarming is the fact that young Papuans aged 15-29 years of age comprised 55 percent of cumulative AIDS cases up to March 2011. Studies have shown that sexual permissiveness is becoming more common among young people in Indonesia and in both provinces. However, young Papuans still have a low level of comprehensive knowledge on Human Immunodeficiency Virus (HIV) and AIDS, do not perceive themselves at risk of HIV infection, and rely mostly on the media as the main source of information on HIV and AIDS. Therefore, education of young Papuans for HIV prevention is important in reducing new HIV infection. This thesis is based on the '2009 Reducing the Risk of HIV Infection: Intervention Trial for Young Papuans' program that I developed. This research is the first cluster-randomized trial on senior high school students carried out in Indonesia, and the first study to evaluate the efficacy of a comprehensive reproductive health education module on senior high school students in Indonesia. This research explores perspectives related to the social norms of sexuality and reproductive health education; evaluates the effectiveness of the 'Reducing the Risk of HIV Infection: Intervention Trial for Young Papuans' program in changing young people's knowledge, attitudes, behavior intentions and sexual practices based on the results of pre-tests and post-tests and self-reported sexual practices among senior high school students in different intervention groups; and analyzes determinants of students' sexual practices. The study uses a combination of quantitative and qualitative methods. The 'Reducing the Risk of HIV Infection: Intervention Trial for Young Papuans' module consists of a handbook and a PowerPoint presentation that has several advantages. It is delivered through interesting methods that enable active participation of the students. It helps students develop positive feelings about their changes during puberty and how to deal with the changes. It provides unbiased information about HIV and AIDS and other sexually transmitted infections (STIs), risk involved in unprotected sexual intercourse, revealing the truth about sexual myths related to Papuan cultures, teenage pregnancy, unsafe abortion, sexual and reproductive rights, how to use condoms and lubricants, available health services, and motivation to achieve a better future. It provides a framework for decision-making and communication about safer sexual practices. Therefore, the program helps students perceive whether they might be at risk for HIV, increases the motivation and intentions to reduce risk, and builds the skills required to protect themselves from acquiring HIV infection or other STIs, as well as unintended pregnancies in the real world. 'Reducing the Risk of HIV Infection Logic Model' is created and used by the author to show clearly and concisely the causal mechanisms through which specific interventions (Reducing the Risk of HIV Infection: Intervention Trial for Young Papuans' program) can affect certain determinants (students' risks and protective factors) that affect behaviors, which in turn (through maintenance) will achieve a health goal (reduction of new HIV infection). The results of in-depth interviews of educators and policy makers confirm the need for a comprehensive reproductive health education module in the school curriculum, the need to raise quality of teachers, and to achieve openness between parents and children. Health professionals suggest young Papuans are reluctant to visit Voluntary Counseling and Testing (VCT) clinics, health centers and private doctors to discuss STIs, due to ignorance, stigma and availability over-the-counter medicine. Further, many young patients come to hospital with late stage of AIDS. A stratified cluster randomized trial is used to assess the efficacy of my intervention strategy A total of 16 senior high schools (1,082 Year 11 students) was selected out of 89 senior high schools in Jayapura city and Jayapura district of Papua Province, and Manokwari district and Sorong city of West Papua Province. These schools were randomly assigned to either receive the reproductive health education program after pre-test (being in the intervention group) or acted as a control group that received the program two months later, after the post-test. The questionnaire consisted of 128 questions: 25 true or false questions in the knowledge test; 30 questions in the attitude test; 18 questions in the behavior intention test; and 55 questions covering demographic characteristics, previous sexual experience, contraception, pregnancy, unsafe abortion, STI symptoms, treatment-seeking behavior, interest in reproductive health matters, alcohol and drug use. Total loss to follow-up on individual level was 8.7 percent (94 students), corresponded to 988 students in the analysis. Changes in knowledge, attitudes, behavior intentions and sexual practices between the two groups were compared using linear mixed models and generalized linear mixed models to account for the cluster randomized design. Of the 988 students in the analysis, 48.8 percent were in the control groups, and 51.2 percent were in the intervention group. The mean age of respondents was 18.9 years. The characteristics of intervention and control groups were similar with respect to sex, school type, ethnicity, sexual orientation, previous sexual experience, alcohol and drug use, source of HIV and sexuality information and enthusiasm to know about reproductive health education. However, the two groups were dissimilar with respect to religion; which was likely to be due to the clustered nature of the data. Results of linear mixed model indicated that 'Reducing the Risk of HIV Infection: Intervention Trial for Young Papuans' module achieved an efficacy with almost three more correct answers (difference score was 2.6 points, 95% CI 2.1, 3.1) for the overall knowledge test, 2.5 points (95% CI 0.3, 4.8) better mean score for the overall attitude test, and 2.4 points (95% CI 0.5, 4.2) better mean score for the overall behavior intention test different from pre-test to post-test between intervention and control group. Reducing the Risk of HIV Infection: Intervention Trial for Young Papuans module showed an efficacy of 0.4 times (95% CI 0.3, 0.7) in reducing the risk of having sexual intercourse and five times (95% CI 1.5, 14.9) in increasing condom use in the last sexual intercourse. The study supports the hypothesis that 'Reducing the Risk of HIV Infection: Intervention Trial for Young Papuans' module has been effective in changing young people's knowledge, attitude, behavior intention and sexual practices related to HIV and sexuality towards more positive results
