1. Risky sexual activity among young men in Nepal Govinda Prasad Dahal, Monique Hennink and Andrew Hinde Division of Social Statistics Prepared for the CAR seminar series, 16 February 2005, University of Southampton

2. Structure of Presentation 2 Rationale of the study 3 Data and methods 4 Findings 5 Conclusions 1 Objectives 6 Some Interventions

3. Objectives To examine the extent and nature of sexual risk taking behaviour amongst young men in Nepal. a) measures the prevalence of sexual activity and risky sexual behaviour b) identifies contributing factors to sexual activity and risky sexual behaviour Specifically, the study

5. Rationale Trend of detected HIV/AIDS cases by gender: 1988-2004 Source: National Centre for AIDS and STD Control, MOH, Kathmandu, April 30, 2004

6. Rationale  HIV prevalence has moved from a ‘low’ to ‘concentrated’ epidemic (REGHED, 2000) and is rising rapidly (FHI, 2002)  Ratio of male/female is 3:1, mostly men under 25 years (NCASC, 2001).  approximately 61,000 people living with HIV/AIDS in Nepal (UNDP, 2004).

7.  Despite cultural taboos on sexual behaviour, increasing HIV prevalence indicates young people’s involvement in risky sex  About 33% of the population are aged 14-22  No research on sexual behaviour of young people using large scale data Continued …….  Without intervention, AIDS would be the leading cause of death in adult population (MEH 2000).

8. Data and methods  Nepal Adolescents and Young Adult (NAYA) Survey 2000  First large scale survey on young people including sexual behaviour and family planning.  Stratified, two-stage sampling design using probability proportional to size. Quantitative data:

9. continued….  7,977 males and females aged 14-22 years  3,802 males of which 613 were married  logistic regression models  Questions asked on: Ever had sex, Age at sexual debut, Partners (type, regularity, number), Condom use/ no-use

10. Continued…. Focus group discussions with Nepali young males aged 14-22 years Thematic analysis Qualitative data:

11. Summary of Socio-economic status: Nepal GDP per capita for 1999/2000: US$ 244. More than 80% people reside in rural area. Agriculture as the main occupation. Marital pattern-Universal. Median age at first marriage: Women 15-49: 16.6 yrs Men 15-59 : 19.7 yrs

12. Median age at first sexual intercourse Women 15-49: 16.7 yrs Men 15-59 : 18.8 yrs Literacy: men 70% and women 35%. Religion: Over 80% Hindus. Main Communication media: Radio. Contraceptive prevalence Rate: 39% Summary of Socio-economic status: Nepal

13. Definition of Risky Sexual behaviour “P ersons with multiple partners in the last 12 months, plus persons with one non-regular partner where a condom was NOT used.”

14. Total sample = 3189 N = 38Y=20N=22Y = 46 How many partners? 1 = 842+= 42 Ever had sex? No = 2924Yes = 265 Sex in past year? No = 139 Yes = 126 CP? Y=5N=33Y=16N=4N=22Y=0 Y=22 N=11 Y=4N=1Y=8N=8Y=2N=2Y=11N=11 CU? Key: CP = Commercial partners; CU = Condom use Identification of Single Men’s Risky Sexual Behaviour Regular partners?

15. Total sample = 613 Ever had sex? No = 93Yes = 519 Yes = 501 How many partners? 1 = 461 2+= 40 Y = 455N = 6 Y=1 Y=31N=9 Sex in past year? No = 18 CP? N=5Y=1Y=22N=9N=3Y=6 CU? Y=1N=4Y=9 N=13 Y=3N=6Y=1N=2 CU? Y=2N=4 Key: CP = Commercial partners; CU = Condom use Identification of Married Men’s Risky Sexual Behaviour Regular partners?

16. Data Limitations Lifetime risk cannot be measured from the NAYA data: “How many different sexual partners have you had in the past year?” Cumulative risk is not identified

17. Key Findings (Prevalence)  9 in 10 married men are sexually active  Of those:  1 in 11 engaged in extra-marital sex  1 in 11 are engaged in risky sex  1 in 12 single men are sexually active  Of those, 1 in 5 engaged in risky sexual activities

23. Key Findings on sexual activity among single men: Multivariate analysis unemployed and students were less sexually active than their other counterparts rural residents were more sexually active than urban hill residents were more sexually active than terai Sexual activity increases with age

24. Key Findings on risky sex among single men: Multivariate analysis Single men having risky sex are from: western hills literate mothers BUT those listening to RH radio programmes reduced risky sexual behaviour

25. unemployed and students were less sexually active than their other counterparts rural terai residents were less sexually active than hill residents sexual activity increases with age Married men more likely to engage in risky sex are: secondary or higher educated father is educated Key Findings on sexual activity among married men: Multivariate analysis Key Findings on risky sex

26. Why males from hills have high risk sexual behaviour? Qualitative results show a range of factors: Opportunistic sex When they meet in the forest or bushes and if no one is around, they hurriedly want to finish as soon as possible. They do not have time to think about condoms (FGD2: young rural man, 16 year). Only want to experiment …teen-agers either think about pregnancy and sexually transmitted infections or think about condom use. They just want to experiment with sex (FGD2: 16 year urban boy) Fear of harassment When unmarried men go to buy condoms salesperson harass them and also warn that (s)/he will tell to his parents or family (FGD2: 18 year boy)

27.  Negative attitudes towards condom use  Privacy and carelessness..migrated people who have rented room away from natal home are free from the close supervision of their parents. No one is there to disturb them. They are even free to bring girls at any time and have sex. They often do not think about condom use since they do not care about the future consequences (FGD1: young man, 20 year, hill region). Young people who know about condoms still do not use them because these people have strong feelings not to miss the natural taste (FGD1: 19 year boy) Why are hill men engaged in risky sex?

28. Conclusions  despite strict cultural taboos, young men are involved in pre and extra marital sexual relationships and in risky sexual practices  Nepal is in the early stage of HIV epidemic, but the nature of risky sex indicates men’s vulnerability to HIV transmission, unless interventions reach this target group.

29. Conclusions (continued..)  Sexual risk taking is not limited to urban areas, it is even higher in rural and hill areas than in urban and Terai  Respondents who listened to all reproductive health programs on the radio are more likely to be sexually active but less likely to engage in risky sex  young men’s involvement in risky sex jeopardises their own and their wife / partner’s sexual health  young men could under-report their sexual act

30. Some interventions are suggested: Both school and community based family life education is important. Curriculum should provide basic RH information in order to promote better communication between children, parents and teachers Training Health Workers on how to deal with Young Peoples’ Sexual Health Needed Effective communication programs in sexual health is needed

31. Acknowledgement  Dr. Prescilla Ackwara- Micro-International  Dr. John Cleland- LSHTM  Dr. Shyam Thapa – Family Health International  All who provided comments during oral presentation (based on only quantitative data) at PAA in Minneapolis, USA.