Association between Risky Sexual Behaviour and having STIs or HIV among young persons aged 15-24 years in Uganda Gideon Rutaremwa§1, Peninah Agaba2, Elizabeth Nansubuga2 and Olivia Nankinga2 §Correspondence: [email protected] 1 United Nations Economic Commission for Africa (ECA), Social Development Policy Division, P.O.Box 3001, Addis Ababa, Ethiopia 2 Center for Population and Applied Statistics (CPAS), and Department of Population Studies, Makerere University, P.O.Box 7062, Kampala, Uganda Author contacts GR: [email protected] PA: [email protected] EN: [email protected] ONJ: [email protected] Abstract Adolescent pregnancy is often discussed in literature as causes of health concern and as a social problem. Taking these accounts as a starting point, this paper uses the 2011 Uganda AIDS Indicator Survey (UAIS) data to explore the factors related to sexual behaviour and risk of STI and HIV infection among youths in Uganda. A total of 2,491 males and female young persons were selected for this study. A complementary log-log regression model was used to examine the association between women’s risky sexual behaviour and having an STI, HIV, and any STI including HIV. Female youths were more likely to contract an STI and HIV compared to their male counterparts (OR=2.1; 95% CI=1.2-3.6). The risk of contracting STIs was higher in Western Region of Uganda compared to Central region (OR=1.4; 95% CI=1.0-1.9). At the same time youths in Eastern Uganda had the least odds (OR=0.63) of contracting STIs. Furthermore, youth with multiple sex 1 partners were more likely to contract STIs including HIV compared to those who had a single partner. Finally, young persons from the top two wealth quintiles were more likely to test positive for HIV compared to those who belonged to the lowest wealth quintile. The discourse in this paper shows that the youthful age category is a serious policy intervention target that requires redress. Keywords: Sexual behavior, sexually transmitted infections, HIV/AIDS, Women, Uganda Background Risky sexual behaviour are of particular concern to reproductive health practitioners and other primary care clinicians in that they can lead to serious consequences both for the individual and their sexual partners. Both STIs and HIV have potential to undermine development in many ways, including loss of productivity, supply of human capital, agricultural productivity and food security (Muthengi, 2009). Researchers, development practitioners, and medical personnel are faced with 3 challenges: First, how to understand this behaviour, second, how to identify risky sexual behaviour, and third what to do about it. Risky sexual behaviour can take several forms, including unprotected intercourse, multiple or concurrent sexual partners and unsafe sexual intercourse under the influence of substances such as alcohol (Kalichman & Simbayi, 2011; Rosenberg et al., 2015). Among the risk factors for contracting STIs are sexual violence and mental health. Studies indicate that intimate partner violence is frequently associated with increased HIV risk in women. This observation is partly because men who abuse their wives also exhibit riskier sexual behaviour (Dude, 2011; Silverman, Decker, Saggurti, & Donta, 2008). Factors found to be associated with sexual violence have also been identified as risk factors for contracting an STI. Data on the relationship between mental health most commonly identified as depression and STIs is mixed, but most studies report a positive correlation between depression and risky sexual behaviour, an established precursor to STIs (Buffardi, Kathy, King, & Manhart, 2008; Shrier, Harris, Sternberg, & Beardslee, 2001). Similarly, research suggests a positive relationship 2 between alcohol use (Burns, 2015; Kalichman & Simbayi, 2011; Ritchwood, Ford, DeCoster, Lochman, & Sutton, 2015; Rosenberg et al., 2015; Yi et al., 2014), drug and other substance use (Lansford, Dodge, Fontaine, Bates, & Pettit, 2014; Manhart et al., 2006), multiple sexual partners (Chimoyi & Musenge, 2014; Kalichman & Simbayi, 2011) and STI risk. Concerning age, risky sexual behaviour is known to cut across all age groups. Reports of adults having had two or more sexual partners in the previous year are also common (Ministry of Health -Uganda and ICF Macro International Calverton Maryland USA, 2012) . Why should researchers care about risky sexual behaviour among young ages? One reason why this issue is important is that risky sexual behaviour increases the likelihood of contracting an STI including HIV/AIDS. It is clear that sexual activity is common among individuals in the reproductive ages, and many of the behaviour that they engage in put women at risk for contracting STIs or HIV. This paper seeks to contribute to the concern of risky sexual behaviour and its link with STIs and HIV among young persons in Uganda. Uganda has long been regarded as an HIV success story. This was because the Ugandan government initiated a robust response to the epidemic that was praised as a model response to the HIV epidemic bringing about a substantial fall in HIV prevalence (Kibombo, Neema, & Ahmed, 2007; Kilian et al., 1999; Kirby, 2008). HIV prevalence declined from a peak of 15% in 1990/91 (Kibombo et al., 2007; Murphy, Greene, Mihailovic, & Olupot-Olupot, 2006) to a low of 6.2% in 1999/2000 before increasing to 6.4% in 2004/05. The fall in HIV prevalence observed during the 1990s was statistically significant (Shafer et al., 2011). Factors influencing the recent trends of the epidemic are not yet clear, but there are indications that the observed changes may partly be explained by the increased risky sexual behaviour. A recent Ugandan study (Tumwesigye et al., 2012), showed that 63% of men and 59% of females had unprotected sex during their last sexual encounter. No doubt, the prevalence for HIV/AIDS in Uganda continued to increase to 6.7% from 6.4% (Ministry of Health- Uganda and ICF Macro International Calverton Maryland USA, 2012) . 3 It is against this background that this research was conducted to contribute to the current debate of why there is seemingly a reversal in the earlier gains in the fight against HIV/AIDS in Uganda. It is our belief that an improved understanding of factors associated with STIs or HIV infection among young people of Uganda will lead to improved policy frameworks and programming, ultimately reducing the cases of STIs or HIV infection in this country, which has for two decades been negatively affected by STIs including HIV/AIDS. Methods Data Source Data from the 2011 Uganda AIDS Indicator Survey (AIS) were used for this study. The AIS data provide information on knowledge, attitudes and sexual behaviour related to HIV/AIDS and other indicators such as HIV testing, access to antiretroviral therapy, services for treating sexually transmitted infections, and coverage of interventions to prevent mother to child transmission of HIV. Informed consent was sought from all study respondents. The protocol for the blood specimen collection and analysis was developed jointly by all parties to the survey and was reviewed and approved by the Science and Ethics Committee of the Uganda Virus Research Institute (UVRI), ICF Macro’s Institutional Review Board and a review committee at the Centers for Disease Control and Prevention (CDC) in Atlanta. It was also cleared by the Ethics Committee of the Uganda National Council of Science and Technology (Ministry of Health- Uganda and ICF Macro International Calverton Maryland USA, 2012). Furthermore, permission was sought from ICF Macro International to use the AIS data set. Explanatory variables The independent variables considered in the analysis included respondent’s: age, residence, marital status, wealth status, region, educational level attainment, age at first sexual intercourse, consistent condom use with the last three sexual partners, alcohol 4 intake by either the respondent or partner before sexual intercourse and number of life time partners. The association between these predictor variables and STI or HIV infection was the primary relationship of interest. Dependent variable The dependent variable is dichotomous, that is, whether the respondent had an STI or HIV infection or not. Women were asked if they had ever suffered from any STI in addition to experiencing any genital discharge or genital sores in the year preceding the survey or during the last 12 months. In addition, these women were tested for HIV/AIDS. Sampling This study is based on data from a wei ght ed sample of 2,491 young persons, both male and female, aged between 15-24 years who had ever had sex in the 4 weeks preceding the AIS Survey and were tested for HIV/AIDS during the Uganda AIDS Indicator Survey (AIS) of 2011. The 2011 AIS was a nationally representative population based sample, designed to obtain national and sub-national estimates of the prevalence of HIV and syphilis infection. Information was collected on both the covariates and dependent variable used in the current study. The sample for the Uganda AIS of 2011 is deemed adequate to allow for analysis, comparisons and is also useful in identification of important factors associated with sexual behavior in the era of HIV/AIDS in Uganda. Statistical analyses Analysis in this study was done in two stages, first the descriptive analysis to describe the characteristics of youth and their sexual behaviour. Secondly, to examine the association between risky sexual behaviour and having STIs or HIV, three models were fitted including STI (Model 1), HIV (Model 2) and any STI including HIV (Model 3). The likelihood of having an STI or HIV was fitted using a complementary log-log regression reporting odds ratios based on the 95% confidence interval (Table 3). The significance level of the predictor variables was set at p<0.05 for the regression model coefficients. Typically this model is used when the positive (or negative) outcome is rare as is the case with the current data, and is an alternative to logit and probit analysis.