AIDS Behav (2011) 15:228235 DOI 10.

1007/s10461-010-9757-1

ORIGINAL PAPER

Behavioral Surveillance of Premarital Sex Among Never Married Young Adults in a High HIV Prevalence District in India
G. Anil Kumar Rakhi Dandona S. G. Prem Kumar Lalit Dandona

Published online: 13 July 2010 Springer Science+Business Media, LLC 2010

Abstract In a population-based representative sample of 2,475 never married persons aged 1524 years from Guntur district of Andhra Pradesh state in India, 21.7% (95% CI 18.724.7) males and 4.6% (95% CI 2.27.0) females reported having had sex. Only 22.3% males and 6.3% females reported consistent condom use for premarital sex in the last 6 months. The strongest associations with premarital sex for males were current use of alcohol and tobacco, and for females were not living with parents currently and being an income earner. These ndings can inform HIV prevention efforts among young adults in India. Keywords HIV India Population-based Premarital sex Young adults

Introduction Worldwide, young adults aged 1524 years accounted for 45% of new HIV infections in 2007 [1]. The importance of preventing HIV in young adults is emphasized in the 2001 Declaration of Commitment on HIV/AIDS that proposed substantial reduction of HIV prevalence in young people in the most affected countries [2]. Although the HIV burden estimate for India has been revised downwards recently based on population-based
G. A. Kumar (&) R. Dandona S. G. P. Kumar L. Dandona ISID Campus, Public Health Foundation of India, 4 Institutional Area, Vasant Kunj, New Delhi 110070, India e-mail: anil.kumar@ph.org L. Dandona Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA

data, India still has one of the highest numbers of persons living with HIV in the world [1, 3]. Young adults aged 15 24 years make up nearly a fth of Indias population, and their sexual behavior has important implications for determining the future of the HIV spread in India. Studies that report population-based correlates of premarital sex in India are rare. Among Indian states, Andhra Pradesh has the highest HIV burden where about half of the new infections are estimated to occur in high-risk groups and half in the general population [3, 4]. Antenatal sentinel surveillance in pregnant women in public sector hospitals in Guntur district of this state suggests that this district has one of the highest HIV prevalence in the state [3]. We have previously reported a population-based estimated of 1.72% HIV prevalence in the 1549 years age group in Guntur district, with adjustment for under-represented high risk groups making the adult prevalence 1.79% [5]. In this population-based study, 22% of the HIV cases were found in those who were 1524 years of age at the time of the survey [5]. From the same study we now report the prevalence of premarital sex and its associations that could inform HIV prevention in India.

Methods A cross-sectional population-based survey was carried out in Guntur district of Andhra Pradesh, India on a sample representative of the adult population in this district. Ethics approval for this study was obtained from the Institutional Ethics Committees of the Administrative Staff College of India and Nizams Institute of Medical Sciences, Hyderabad, India. The detailed methodology of this population based study has been published previously [5]. The methods relevant for this paper follow.

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This study was conducted in 32 rural and 34 urban clusters selected using a stratied random method to represent the adult population of Guntur district. Systematic sampling was done to select households in order to get 200230 eligible persons 1549 years old in each cluster. Using this sampling strategy, a total of 13,838 eligible people 1549 years of age were sampled of which 5,002 were 1524 years of age whom we dened as young adults for this analysis. Data were collected from September 2004 to September 2005. Trained interviewers obtained informed consent from eligible people for participation in the study. They then conducted condential interviews of participants in a private setting inside or near the house of the respondent to get information about their socio-demographic background, sexual and other behaviour that may be associated with HIV. Socio-demographic information included age, sex, ruralurban residence, education, standard of living index, occupation and marital status. The standard of living index was based on living conditions and ownership of assets, which was adapted from an index used previously by the National Family Health Survey in India, with higher score meaning higher living standard [5]. Information related to personal behaviour included sexual behaviour included time away from home in the last 6 months, travel alone, living with parents currently, current use of alcohol and current use of tobacco, age at rst sex, number of lifetime sex partners, type of sex partners in last 6 months, and condom use for sex in last 6 months. All participants irrespective of marital status were asked about their sexual behavior in a sensitive manner. Extensive effort was made to elicit sexual behavior history as accurately as possible by making the respondent comfortable and informing her/him that their responses would be condential and that their individual identiers will not be linked with the data analysis. Data were entered in a MS Access database designed for this study by data entry operators, which were fully checked by another data entry operator to detect and correct errors. Data were analysed using SPSS software Version 15 (SPSS Inc, Chicago, Illinois). We analysed only the hetrosexual behaviour of respondents for this report. The main outcome variable assessed was the prevalence of premarital sex among young adults who were never married. The prevalence rate was adjusted for the age, and urban-rural distribution of the Guntur district, and the 95% condence intervals (CI) were adjusted for design effect (DE) due to the cluster sampling strategy. We performed univariate and multivariate analyses to understand the associations of premarital sex by young adults with various socio-demographic and behavioral characteristics. We analyzed these associations separately for male and female. In the multiple logistic regression models, the effect of each category of a multi-categorical variable was assessed

by keeping the rst or last category as reference and all the variables were introduced simultaneously in the model. If condom was used always or often during sex in the last 6 months, we considered this as consistent condom use for this analysis. A respondent was considered to have knowledge about the sexual mode of HIV transmission if s/ he mentioned that HIV could be transmitted through sex with an HIV infected person, with female sex workers, with multiple partners, for men through having sex with other men, and having sex without condom. We also analyzed data from the National Family Health Survey-3 (NFHS-3) of 20052006 for prevalence of premarital sex among never married young adults in Andhra Pradesh state [6].

Results Of the 5,002 sampled persons 1524 years of age, 2,645 (52.9%) were never married of whom 2,475 (93.6%) were interviewed including 2,420 (91.5%) who provided information about sex behavior. The participation rate among the never married 1524 years old was slightly lower for females (89.7%) than males (92.4%) and slightly higher for rural residents (93.9%) than the urban residents (89.9%). Distribution of Premarital Sex Of 1,642 never married males and 778 never married females, 342 (20.8%) and 39 (5.0%) reported ever having had sex, a prevalence of 21.7% (95% CI 18.724.7, DE 2.28) and 4.6% (95% CI 2.27.0, DE 2.72) respectively adjusted for the age and rural-urban distribution of Guntur district. Of 342 males and 39 females who reported having ever had premarital sex, 184 (53.8%) and 32 (82.1%) respectively reported having had premarital sex in the last 6 months. The number of lifetime sex partners for males ranged from 1 to 50 (mean 4.1, median 2), and for females ranged from 1 to 10 (mean 1.4, median 1). The average number of sex partners per sex-life-year increased with increasing years of sex life for both males and females (Table 1). The mean age at rst sex for males was 16.8 years (95% CI 16.617.0, range 923), slightly lower for rural (16.7 years) than urban males (17.0 years). The mean age at rst sex for females was 15.7 years (95% CI 15.016.4, range 1321), and was lower for rural (15.2 years) than urban females (16.3 years), (Table 1). The scatter plot comparing the current age of the respondents with the age at rst sex indicates that the age at rst sex has declined over the last few years among both young females and males (Fig. 1). The proportion of male young adults reporting sexual debut below the age of 15 years was 17.5%, where as this proportion for females was 33.3%.

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Table 1 Number of lifetime sex partners and age at rst sex for never married young adults aged 1524 years in Guntur district of India Variable Variable categories Never married 1524 years old males (N = 1,642) Mean number of lifetime sex partners (range) Age (years) Education Place of residence Standard of living index quartiles 1519 2024 No schooling Any schooling Urban Rural 016 1722 2329 Type of sex partner in the last sex encounter 3054 Lover/boy or girl e friend/ance Class mate/ co-worker/friend Relatives Female sex workers Others Not stated Sex life years (years) B1 23 45 [5 2.7 (150) 3.7 (125) 3.7 (115) 3.1 (150) 3.4 (150) 3.0 (120) 2.9 (115) 2.8 (120) 3.6 (150) 3.7 (125) 3.1 (150) 2.4 (115) 1.9 (17) 4.2 (120) 2.0 (22) 3.4 (116) 2.0 (115) 3.4 (150) 3.6 (120) 5.3 (120) Mean age at rst sex (years) 15.8 18.0 16.4 16.9 17.0 16.7 16.3 16.8 17.1 17.5 16.9 16.6 16.6 16.6 17.2 19.0 16.7 19.0 17.8 17.5 15.1 4.7 (210) 1.0 (110) 1.0 (11) 1.1 (12) 1.5 (12) 6.0 (210) 13.7 15.5 16.7 17.6 15.0 14.5 Never married 1524 years old females (N = 778) Mean number of lifetime sex partners (range) 1.1 (12) 2.8 (110) 2.1 (110) 1.0 (12) 1.6 (110) 1.1 (12) 1.7 (110) 1.0 (11) 1.0 (11) 1.1 (12) 1.1 (12) 1.0 (11) 1.0 (11) 1.0 (11) Mean age at rst sex (years) 15.3 19.0 15.3 15.9 16.3 15.2 14.7 14.9 16.0 17.8 16.4 15.8 17.5 15.0

Known person/neighbour 3.8 (120)

Fig. 1 Relation between the respondents current age and age at rst sex among never married males and females 1524 years of age in the Guntur study

Types of Sex Partner Of 342 males and 39 females who reported having ever had premarital sex, data on the type of sex partner with whom

they had sex in the last sex episode was available for 254 (74.3%) male and 22 (56.4%) female participants, respectively. The last reported sex partner for males was e (43.7%), classmate/co-worker/friend lover/girlfriend/ance

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(22.4%), a female sex worker (FSW, 17.3%), known person/neighbour (9.8%), relative (6.3%) and others (0.4%). Of the 22 females who had reported the type of sex partner, e, 6 10 (45.5%) had sex with their lovers/boy friend/ance (27.3%) with classmate/co-worker/friend, 2 (9.1%) with relative, 1 (4.5%) with known person/neighbour and 3 (13.6%) with others. Distribution of Non-Use of Condom In the last sex episode, 212 (62.0%) males and 35 (89.7%) females reported not using condom (Table 2). For both males and females non-use of condom in last sex was relatively high with all types of sex partners (range 62.5 100%) except males with female sex workers (15.9%). Males residing in rural areas reported higher condom non-use in last sex (73.9%) than those residing in urban areas (47.4%), which was statistically signicant (v2 = 25.29, P \ 0.001). Females residing in rural areas also reported

higher condom non-use in last sex (95.2%) than those residing in urban areas (77.8%), but this did not reach statistical signicance (v2 = 2.64, P = 0.104). Non-use of condom in last sex was reported to higher by those with no schooling versus those with any schooling, but this not reach statistical signicance for either males (v2 = 1.30, P = 0.255) or females (v2 = 1.98, P = 0.160). Of 184 male and 32 female respondents who reported participating in sex in last 6 months, only 41 (22.3%) and 2 (6.3%) reported consistent use of condom respectively (Fig. 2). The proportion of consistent use of condom was signicantly higher among males as compared with females (P = 0.035). The consistent use of condom was 1.6 times more in urban males than rural males, whereas the percent of consistent use of condom was similar for both urban and rural females. None of the females aged 2024 and standard of living index less than 30 reported to have consistent use of condom in the last 6 months, but consistent use of condom was 2.5 times more in males with

Table 2 Condom use in last sexual encounter by never married young adults aged 1524 years in Guntur district of India Variable Variable categories Never married 1524 years old males (N = 1,642) Ever had sex N Age (years) Education Place of residence Standard of living index quartilesa 1519 2024 No schooling Any schooling Urban Rural 016 1722 2329 3054 Type of sex partner Lover/boy or girl e in the last sex friend/ance encounter Class mate/ co-worker/friend Relatives Known person/neighbour Female sex workers Others Sex life years (years) Not stated B1 23 45 [5
a

Never married 1524 years old females (N = 778) Ever had sex N 34 5 10 29 18 21 15 7 7 10 10 6 2 1 3 No condom use in last sexual encounter N (%) 31 (91.2) 3 (60.0) 10 (100) 24 (82.8) 14 (77.8) 20 (95.2) 14 (93.3) 7 (100) 7 (100) 6 (60.0) 7 (70.0) 6 (100) 2 (100) 1 (100) 2 (66.7) 16 (94.1) 22 (91.7) 9 (81.8) 2 (100) 1 (50.0) 2.14, 0.143 4.19, 0.523 9.17, 0.027 2.64, 0.104 1.98, 0.160 Chi-square value, P value 3.79, 0.052

No condom use in last sexual encounter N (%) 113 (63.5) 99 (60.4) 32 (69.6) 180 (60.8) 73 (47.4) 139 (73.9) 72 (72) 58 (59.2) 55 (56.7) 27 (57.4) 80 (72.1) 39 (68.4) 10 (62.5) 19 (76.0) 7 (15.9) 1 (100) 56 (63.6) 60 (58.3) 86 (63.7) 39 (57.4) 27 (75.0)

Chi-square value, P value 0.35, 0.553 1.30, 0.255 25.29, 0.000 6.14, 0.105

178 164 46 296 154 188 100 98 97 47 111 57 16 25 44 1 88 103 135 68 36

35.76, 0.000

1.32, 0.251

17 24 11 2 2

Standard of living index based on living conditions and ownership of assets, with 0 as the lowest score and 54 the highest

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232 Fig. 2 Consistent use of condom among never married young adults aged 1524 years for sex in the last 6 months in the Guntur study

AIDS Behav (2011) 15:228235

low standard of living index score (22 or less) than in those with higher index score. Associations of premarital sex and non-use of condom With multiple logistic regression (Table 3), the highest odds for premarital sex among males were associated with current consumption of alcohol (3.50, 95% CI 2.534.83) followed by current use of tobacco (2.81, 95% CI 2.043.87) (model R2 = 0.35). Males in the highest standard of living index quartile, those who were income earner, those who travel alone, those aged 2024 years, those living in rural area, those who reported being away from home in the last 6 months, and those having knowledge about sexual mode of HIV transmission had signicantly higher odds of having had premarital sex (Table 3). On the other hand for females, not living with parents currently (4.79, 95% CI 1.6413.97), being an income earner (2.98, 95% CI 1.296.89), and travel alone (2.71, 95% CI 1.255.89) were signicantly associated with premarital sex (model R2 = 0.17). A similar multiple logistic regression model assessing associations with condom non-use for last episode of premarital sex revealed that for males the only signicant association was with rural residence, 3.64 higher odds (95% CI 2.166.13) versus urban residence. Males with no schooling had substantially higher odds of condom non-use than those with any schooling but this was not statistically signicant (1.97, 95% CI 0.924.18). For females none of the associations were signicant due to small numbers reporting premarital sex, with the vast majority of them reporting non-use of condom. National Family Health Survey-3 (NFHS-3) Of 1,436 never married males aged 1524 years in the state of Andhra Pradesh who provided information on sexual

behaviour in this survey, 170 (11.8%) reported ever having had sex, a prevalence of 12.4% (95% CI 10.714.1) adjusted for the age and rural-urban distribution of Andhra Pradesh state, where as of the 1,458 never married females in this age group who provided information on sexual behaviour none reported to have had premarital sex. Among the males who reported ever having had premarital sex, 15.1% reported having used condom in their last sex encounter.

Discussion Young people aged 1524 years account for 45% of all new HIV infections in adults globally, and many of them lack accurate and complete information on how to avoid exposure to the virus [1]. This paper proles the distribution and correlates of premarital sex among never married young adults aged 1524 years in a high HIV prevalence district in the Indian state of Andhra Pradesh. The HIV epidemic cannot be reversed without success in preventing new HIV infections, in young adults in particular as nearly half of the worlds population is below 25 years of age. A large proportion of the new HIV infections in India are estimated to occur among young adults. One in six never married young adult aged 1524 years reported premarital sex in this representative populationbased sample in the state of Andhra Pradesh. This nding is similar to those reported from previous studies less representative in nature and with smaller samples [7, 8]. However, as the comparison suggests, the rate in our study was higher than that reported in NHFS-3 for Andhra Pradesh state. The zero premarital sex reported by over 1,450 never married young females in NFHS-3 seems implausible, suggesting inadequate probing of this socially undesirable behavior during the interview. The district-level sample

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Table 3 Association of premarital sex among never married young adults aged 1524 years with select variables using multiple logistic regression in Guntur district of India Variable Variable categories Never married 1524 years old males (N = 1,642) Number Ever had sex, number (%) Odds of having premarital sex (95% condence interval) 1 1.88 (1.402.54) 1.18 (0.741.87) 1 1 1.76 (1.282.40) 2.11 (1.363.28) 1.81 (1.162.82) 2.66 (1.634.34) 1 2.47 (1.653.69) 1 1 1.73 (1.272.34) 1 2.14 (1.054.37) 1 0.91 (0.621.34) 1.60 (0.912.82) 1.87 (1.372.56) 1 3.50 (2.534.83) 1 2.81 (2.043.87) 1 Never married 1524 years old females (N = 778) Number Ever had sex, number (%) Odds of having premarital sex (95% condence interval) 1.99 (0.685.83) 1 1.94 (0.735.12) 1 1.13 (0.512.48) 1 1.35 (0.444.13) 0.66 (0.212.05) 0.76 (0.262.23) 1 2.98 (1.296.89) 1 1 1.18 (0.542.59) 1 2.71 (1.255.89) 1 1.25 (0.513.10) 4.79 (1.6413.97) 1.88 (0.884.03) 1

Age (years)* Education*# Place of residence*# Standard of living index quartile*#

1519 2024 No schooling Any schooling Urban Rural 016 1722 2329 3054

1,091 551 146 1,496 921 721 302 431 428 481 1,083 559 695 947 165 1,477

178 (16.3) 164 (29.8) 46 (31.5) 296 (19.8) 154 (16.7) 188 (26.1) 100 (33.1) 98 (22.7) 97 (22.7) 47 (9.8) 302 (27.9) 40 (7.2) 95 (13.7) 247 (26.1) 11 (6.5) 331 (22.4) 256 (19.4) 58 (24.3) 28 (32.6) 258 (24.3) 84 (14.4) 179 (50.1) 163 (12.7) 196 (45.4) 146 (12.1)

614 164 79 699 517 261 130 173 193 282 287 491 339 439 553 225 631 117 30 393 385 1 773 2 774

34 (5.5) 5 (3.0) 10 (12.7) 29 (4.1) 21 (8.0) 18 (3.5) 15 (11.5) 7 (4.0) 7 (3.6) 10 (3.5) 25 (8.7) 14 (2.9) 13 (3.8) 26 (5.9) 19 (3.4) 20 (8.9) 25 (4.0) 8 (6.8) 6 (20.0) 25 (6.4) 14 (3.6) 1 (100) 37 (4.9) 1 (50.0) 38 (4.9)

Income earner*# Time away from home in the last 6 months* Travel alone*#

Yes No No Yes Never Some times/ often/always

Living with parents currently*#

With both parents 1,317 With one parent No 239 86 1,060 582 357 1,285 432 1,210

Knowledge about sexual Yes mode of HIV transmission* No Current use of alcohol* Current use of tobacco*# Yes No Yes No
#

* Chi-square test for signicance, P \ 0.001 for all except living with parents for males (P = 0.005) Chi-square test for signicance, P \ 0.001 for living with parents and income earner for females, education (P = 0.001), place of residence (P = 0.006), standard of living index (P = 0.003), travel alone (P = 0.002), current use of tobacco (P = 0.004)

sizes in NFHS-3 were very small, and therefore direct comparison with our data from Guntur district is not possible. Reliable district level population-based data is useful for locally relevant planning of HIV prevention programs. The reported rate of premarital sex in our study was nearly 5 times higher in males as compared with females. It is possible that females under-reported premarital sex even with extensive probing during condential interviews in our study, as this is not generally accepted in the Indian society. A higher rate of premarital sex was reported by rural males in our study as compared with urban males. Addressing the factors that increase HIV risk and vulnerability is important for HIV prevention programmes. Our data indicate that current use of alcohol and tobacco

were among the strongest correlates of premarital sex for never married young adults. India is experiencing phenomenal increase in alcohol consumption with the age of initiation on an alarming decrease and frequent and heavy consumption of alcohol among the young adults on the increase. As the legal minimum age for alcohol consumption is seldom checked before serving alcohol in India, young adults are vulnerable to a variety of high risk situations including unsafe sex under the inuence of alcohol. The association between premarital sex and alcohol use has been reported previously [7, 8]. Current use of tobacco was also associated with premarital sex, and 26% of our sample reported using tobacco currently. These ndings reinforce the need to target young adults who use

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alcohol and tobacco in HIV prevention programmes, males in particular. In addition, our data also highlight that young adults living away from home and parents, who earn income and travel alone were more likely to report premarital sex. These data can be used to enhance appropriate targeting of young adults for HIV prevention activities. The mean age at rst sex in our population was similar to the median age at rst sex at national level reported in the national youth behavioural survey conducted by the National AIDS Control Organisation in 2006 [9]. The proportion of sexual debut before the age of 15 years among the 1524 years old adults is among the national indicators in the 2001 Declaration of Commitment on HIV/ AIDS [2]. There is evidence from some African countries with high HIV prevalence that the percentage of males and females aged 1519 years who became sexually active before the age of 15 years has declined [1]. Six percent of young adults reported sexual debut below the age of 15 years in our population which is comparable to the 5% reported for Andhra Pradesh and is higher than 3% reported at the national level in the youth behavioural survey [9]. A higher proportion of females had reported sexual debut before the age of 15 years as compared with males in the national survey [9]. Our data suggest that younger adults are starting their sexual life earlier which indicates the urgent need for addressing HIV prevention among this group. As expected, those with a longer sex-life reported signicantly higher number of partners with males more likely than females to report multiple partners. There is very little information on the sex partners of young female adults in e formed the India. Lover, boy/girl friend and ance majority of sex partners in our population. The domination es and FSW has been reported for of lover/girl friend/ance young male adults previously [8]. Nearly 80% young adults reported inconsistent condom use in the last 6 months with females more likely than males to report sex without a condom. Although the overall condom use with the last sex partner among young male adults was reported to be low in our population, the majority used condom for sex with FSW with only 16% reporting non-use of condom. It is possible that this is overreporting of condom use with FSW due to social desirability. We have previously reported that nearly half the clients of FSW in Andhra Pradesh were young adults, and with very low condom use reported by FSW [10]. Our results also suggest disparities in consistent condom use among the young adults as those having lower standard of living index, those aged 1519 years and living in rural areas reported low consistent use of condom compared to others. The national youth survey also reported a higher proportion of urban young adults using condom consistently than rural young adults [9].

Several ways are available to educate young adults about HIV, to ensure their access to prevention commodities and health services, and to encourage them to take steps to avoid HIV transmission. These include schoolbased programmes, community-based programmes, mass media campaigns and youth services [1, 11, 12]. Many of these approaches emphasize imparting life skills to young people that enable them to have a healthy approach to sexuality through appropriate knowledge, attitude and skills. Towards this end the Adolescent Education Programme has been implemented in the states of India through the Department of Education in collaboration with the State AIDS Control Societies [12]. Our data can be used to further enhance the reach of these programmes by targeting the appropriate groups among young adults who are more vulnerable to the risk of HIV infection with the aim to promote delayed sexual debut and safe sexual behavior.

Conclusion This study highlights the prevalence of premarital sex and its correlates in a population-based sample from a high HIV prevalence district in the Indian state of Andhra Pradesh. Condom was not used in the vast majority of premarital sex. These data can be utilized to enhance the ongoing HIV prevention programmes aimed at reducing HIV in young adults in India.
Acknowledgments We thank the study participants; G. Md. Mushtaq Ahmed, Md. Abdul Ameer, G. Brahmananda Reddy, Md. Akbar and S.P. Ramgopal for help with planning and managing the eld data collection, and A. Srinivas Rao for help with coordinating the study logistics.

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Copyright of AIDS & Behavior is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.