NORMAN, LISA R. PhD; UCHE, CHUKWUDUM PhD
IT IS COMMON KNOWLEDGE that the sexual behaviors, including unprotected sexual intercourse and multiple sex partners, that put an individual at risk for HIV transmission are the same as for other sexually transmitted diseases (STDs). Since HIV can be sexually transmitted, individuals exposed to other STDs are at high risk for acquisition of HIV infection. Furthermore, STDs are the most readily modifiable risk factors for the spread of HIV infection. Therefore, persons infected with other STDs constitute an easily identifiable group at high risk for HIV infection.
STD rates have been used as biologic markers of continued high-risk behaviors among persons who are HIV-seropositive. 1–5 STD rates have also been used as surrogate markers of sexual risk behaviors among populations that have not undergone HIV serostatus testing as well as populations exposed to HIV prevention programs. 6–8
Rates of STDs among Jamaican adolescents are high. According to the Ministry of Health in Jamaica, rates of STDs are higher among sexually active adolescents than in any other age group; at least one of four have a history of STD. In 1999, 20% of all cases of genital discharge syndrome were among persons aged 10 years to 24 years. In addition, in the age group of 15 years to 19 years, rates of infectious syphilis were 10.8 cases per 100,000 males and 14.4 cases per 100,000 females during the same time period. 9 In addition, through March 2000, there were 4464 reported AIDS cases; 25% involved adolescents and young adults. 10
Although STD aggregate surveillance data are available, survey data on STDs in Jamaican males, at the individual level, are limited. In a probability sample of males aged 15 years to 49 years, 29% reported ever having an STD. 11 Among males attending an STD clinic in Kingston, Jamaica, rates of genital ulcer disease almost doubled over an 8-year period (9.3% versus 18.2%). 12 In a national sample of Jamaican males, 26% of non-marijuana-smokers and 46% of marijuana smokers reported a history of sexually transmitted infections. 13 Generally, the incidence of sexually transmitted HIV is associated with prevalence and incidence of STDs such as genital ulcers, syphilis, gonorrhea, and chlamydia. Persons with STD (other than HIV disease) are at increased risk for HIV infection. Genital ulcer disease facilitates HIV transmission. Discharge syndromes, including gonorrhea and chlamydia, also seem to increase the risk of transmission. Studies examining the relation between syphilis and HIV have found a twofold to ninefold increase in HIV infection risk associated with syphilis; even after sexual behavior was controlled for, the relation remained statistically significant. 14
One early study determined the incidence of HIV and human T-cell lymphotropic virus type I (HTLV-I) infection among STD clinic attenders in Jamaica. For males, HIV prevalence was almost 4% and HTLV-I prevalence was 7%. There were significant associations between HIV infection and drinking alcohol before sex, cocaine use, number of sex partners, engaging in prostitution (self and/or partner as prostitute), and genital ulcer disease. 15 Adolescents and young adults are typically at greater risk for STD than older persons. 16 Adolescents and young adults have the highest risk for exposure to STD, in part because at this age sexual curiosity, experimentation, and sexual-risk taking are not unusual. Research has found that an increasing number of adolescents are sexually active at an earlier age, which results in a higher cumulative number of their sex partners. In Jamaica, first sexual intercourse occurs for most young people in the teen years. For some males, first intercourse occurs before the age of 10 years. 17 Furthermore, adolescents not only often deny that they might come into contact with anyone with an STD but also tend to have spontaneous rather than premeditated sex, thus hindering preventive actions and increasing the likelihood that such sexually active adolescents will acquire or transmit STD. 18 In addition, worldwide, more than half of all people who have become infected with HIV acquired the virus when they were younger than 25 years of age. 19
Examination of STD/HIV risk-related behaviors among Jamaicans has shown that these behaviors are common. A national survey indicated that 86% of those who were sexually active used no method for avoiding AIDS or other STDs. Furthermore, approximately 25% of the respondents reported they were using condoms less frequently than in the past. 20 In a study of 540 adolescents, 32% of those having sex reported condom use for every act of intercourse. 21 Condom use was also examined among Jamaican adolescents over a 2-year period. In 1994, only 16% of sexually experienced males reported consistent condom use; by 1996, 29% reported consistent use. 22
Other studies have found slightly higher rates of safer sex practices. Three national surveys conducted in Jamaica in 1988, 1989, and 1993 among persons aged 15 years to 49 years showed increases in condom use. From 1989 to 1993, the proportion of those reporting ever using condoms increased from 53% to 79%. Consistent condom use (defined as use every time or most times) with one's main partner increased from 27% to 41%. However, the number of persons reporting having two or more sex partners in a 4-week time frame changed little between 1988 and 1993 (11% in 1988, 17% in 1989, and 14% in 1993). 23 In a recent study of adolescent and young adult males in Jamaica (aged 15–24 years), only 22% reported using condoms consistently (defined as every time). The majority of respondents reported having multiple sex partners in the past 5 years; 31% reported having multiple partners in the 30 days before the interview. 24
Condom use appears to vary by partner type. In a study of 100 sexually active Jamaican male outpatients, the majority of men reported having multiple sex partners, with younger ages being correlated with higher number of partners. Whereas overall condom use was low, it was higher for sex with casual partners than with steady partners. 25
Because of the importance of STD in the transmission of HIV, the current article examines the prevalence and determinants of STDs among a national sample of adolescent and young adult Jamaican males. Variables were chosen on the basis of theoretical and/or empirical evidence of factors associated with high-risk sexual behaviors and STDs. The following factors are examined: 1) frequency of STD symptoms (physical symptoms, medical visits for treatment of symptoms, and self-treatment of symptoms); 2) frequency of STD/HIV-related risk behaviors (sexual activity, number of sex partners, condom use); 3) correlation between sociodemographic characteristics and symptoms of STD (age, education, area of residence, employment status, union status, family life education); 4) correlation between STD/HIV-related risk behaviors and STD symptoms (condom use, number of sex partners); and 5) predictors of STD (significant variables from bivariate analyses).
Data for this analysis were taken from the Reproductive Health Survey of 1997. 26 The original study was based on a three-stage probability sampling design involving geographic areas, dwellings, and respondents, in that order. For the first stage, enumeration districts were used; for the second stage, a predetermined number of dwellings was selected; and for the third stage, eligible respondents from each dwelling were chosen. Adolescent and adult males (aged 15–24 years) and females (aged 15–49 years) were targeted. The research instrument included interviewer-administered questionnaires addressing knowledge, attitudes, and behaviors that affect reproductive health. In all, completed interviews were obtained from 6384 women and 2279 men. In completing the questionnaire, subjects addressed a wide range of STD/HIV-related attitudes and behaviors. Relevant questions covered STD symptoms, age at first intercourse, number of sex partners, condom use at last sex, frequency of condom use, and other related variables. For the current study, data for 1632 sexually experienced males were examined.
Respondents who reported symptoms of STDs in the past year (discharge from the sex organ due to disease; a sore on the sex organ; a visit to a doctor, clinic, or other health center for a sexually transmitted illness such as gonorrhea or syphilis; or self-treatment for a sexually transmitted illness such as gonorrhea or syphilis) were coded as having symptoms of STD. Remaining respondents with no such symptoms were coded as having no symptoms of STD.
Consistent condom use.
Respondents who reported using condoms every time during sexual intercourse with steady partners and nonsteady partners were coded as consistent condom users. Remaining respondents who reported using condoms some of the time or never during sexual intercourse were coded as inconsistent condom users.
Area of residence.
Subjects were categorized by area of residence. Fourteen parishes of residence were recoded in rural and urban categories. Respondents living in the four parishes in which 50% or more of the population lives in urban areas were coded as predominantly urban residents. The remaining respondents were coded as predominantly rural residents.
Multiple sex partners.
Respondents who reported having two or more sex partners in the 3 months before the survey were coded as having multiple sex partners, and those with only one partner were coded as having a single sex partner. Respondents who had not had sexual intercourse in the 3 months before the survey did not address this question.
Respondents who reported working outside the home or having a job but not working the week before the survey were coded as employed. Remaining respondents (those looking for work, those who keep house, students, and those incapable of working) were coded as unemployed.
Family life education.
Respondents who reported having had family life education, either inside or outside the school setting, were coded as exposed to family life education. Remaining respondents were coded as not exposed.
Subjects were trichotomized by union/relationship status. Respondents who reported being married or living with a common-law partner were coded as being in a stable relationship. Respondents who were involved in a visiting relationship or had a girlfriend were coded as being in an unstable relationship. Remaining respondents were coded as being in no relationship.
Both bivariate (chi-square) and multivariate (logistic regression) analyses were used to examine the data. The statistical software used was SPSS (SPSS, Chicago, IL).
Table 1 presents the sociodemographic and behavioral characteristics of participants. The mean age of the sample was approximately 20 years, and the mean number of years of education was 10. Approximately 63% of the sample resided in predominantly rural parishes, and only 9% of all respondents were married or involved in a common-law relationship. Almost 58% of the sample were employed outside of the home. Approximately three fourths of the sample reported being exposed to family life education, either in or outside of the formal school setting.
The mean age at first intercourse was about 14 years. The majority reported having sexual intercourse in the previous 3 months; one third of those had multiple sex partners. About 90% reported ever using condoms, and about two thirds reported using them at last sex. About 38% reported consistent condom use with steady partners, whereas 65% reported the same with nonsteady partners.
Examination of STD symptoms in the previous year showed that 6% of males reported having a discharge from the sex organ and 3% reported sores on the sex organ. Approximately 6% had visited a doctor to receive treatment for a sexually transmitted illness, and 5% reported self-treatment for a sexually transmitted illness. Overall, approximately 9% of males reported some level of STD symptoms in the previous year.
Bivariate Correlations Between Sociodemographic Characteristics and STDs
Table 2 shows the results of the bivariate analysis of STDs and selected sociodemographic characteristics. Only one significant association emerged. Males with symptoms of STD in the past year were much more likely to be older than males with no symptoms. There were no differences between males with STD symptoms and males with no symptoms in terms of union status, area of residence, education, employment status, and exposure to family life education.
Bivariate Correlations Between Sex-Related Attitudes/Behaviors and STD
Table 3 shows the results of the bivariate analysis of STD and sex-related behaviors. One significant association emerged. Males with STD symptoms were more likely to report having multiple sex partners in the 3 months before the survey. There were no differences between males with STD symptoms and males with no symptoms with regard to condom use with both steady and nonsteady partners, condom use at last sex, and history of condom use.
Multivariate Correlations Between Selected Predictor Variables and STD
Table 4 shows the results of logistic regression with STD symptoms as the dependent variable. The chi-square test for the overall model specification indicates the result is significant (P < 0.0001). Overall, 90% of the cases were correctly classified in the categories of the dependent variable. When individual coefficients were examined, significant variables from the bivariate analyses were also significantly associated with STD in the multivariate model. The odds ratio shows that for every additional year of age, the odds of having STD symptoms increased (1.12). In addition, males who reported having multiple sex partners were much more likely (2.80) to have symptoms of STD than males without multiple sex partners.
Sexual initiation began early among the sample, with the mean age of first intercourse being 14 years. Almost half of the sample was sexually active in the 3 years before the interview, and one third had multiple sex partners during this time. Most had used condoms at some time, and about two thirds reported condom use during last sex. Rates of consistent condom use were low, especially with steady sex partners. Almost 9% of the sample reported having symptoms of STD in the previous year.
When logistic regression analysis was employed, age and having multiple sex partners remained significantly associated with reports of having STD symptoms in the previous year. Whereas previous research has indicated the increased risk of STD and HIV infection among adolescents and young adults, our analysis found differences within this age group, with older males reporting more symptoms than younger ones. This finding is supported by previous research examining HIV and STD prevalence rates among other samples of youth, including adolescent and young adult homosexual and bisexual men 27 and homeless youths. 28
Previous research has also found a positive correlation between multiple partnerships and HIV and STD rates and related risk behaviors among various subpopulations. 29–33 Our findings confirm the previous research; young males who reported having multiple sex partners in the 3 months before the survey were almost three times more likely to report symptoms of STD in the previous year than were those with a single partner.
Previous STD and HIV research has also found a significant correlation between condom use and rates of HIV/STD among at-risk populations. 34–37 Therefore, the lack of association between condom use and STD symptoms in this analysis was surprising. However, the lack of significance could be due to the reduced size of the subsample addressing the questions about consistent condom use. Only 45% of the sample reported levels of consistent condom use with steady and/or nonsteady partners.
The association between HIV infection and other STD has been observed in many cross-sectional and case-control studies since the mid-1980s, leading to the hypothesis that STD enhances HIV transmission (termed the STD/HIV cofactor hypothesis). 38 Not only does STD facilitate HIV transmission, but also STD and HIV infection share the same sexual risk factors. Furthermore, given that symptoms of STD can serve as markers for continued high-risk behaviors for both HIV infection and other STDs, decreasing STD and increasing risk-protective behaviors are important in curtailing the spread of HIV.
Numerous studies have shown an association between STD control and HIV transmission. In a study of sex workers in Kinshasa, Zaire, regular STD treatment combined with condom promotion led to a significant decline in the incidence of HIV infection and several STDs, including gonorrhea and genital ulcers. 39 In another study of sex workers, improved STD treatment services were integrated into the existing primary health care facilities. This community randomized trial showed that strengthened STD case management of symptomatic persons led to a 30% reduction in HIV infection over 2 years in the general population. 40
It appears that effective control of STDs should be a key component of any HIV/AIDS control program, especially in areas or subpopulations where STDs are highly prevalent. Approximately 9% of our young sample reported some symptoms of STD in the previous year. It is important to note that this is likely to be a conservative estimate of STD among this sample, because asymptomatic infections (such as chlamydial infections) are not represented. However, on the basis of reported sample data and population estimates for Jamaica, there were an estimated 22,500 cases of STD (not including HIV infection) among sexually active adolescent and young adult males in 1997. Given that about one fourth of them did not seek medical treatment, there are a significant number of young men who are living with symptomatic, untreated STD. On the basis of the above estimates, this number of young males with symptomatic, untreated STD was approximately 6000 in 1997. Furthermore, a large proportion of these males had multiple sex partners and used condoms inconsistently, thereby increasing the risk of STD transmission to uninfected partners. These males put themselves at increased risk of HIV infection or reinfection with other STDs. Not only is this population at increased risk for STD, but it is also at increased risk for HIV infection as well. Approximately two thirds of all reported AIDS cases in Jamaica involve persons aged 20 years to 39 years. 41 Because of the incubation period of HIV, it appears that many of these persons were infected during adolescence and young adulthood. One possible explanation for the high rates of STD and HIV among this group may be the unique risks of exposure for young persons. Adolescents’ sexual activity is often unplanned or sporadic. In addition, experimentation is a normal part of adolescents’ development; unfortunately, it exposes them to health risks. Adolescents’ sexual encounters typically occur before they have any of the following: experience and skills in self-protection; adequate information about STD and STD control; and adequate access to services and supplies such as condoms. 39
Not only are adolescent and young adults in Jamaica faced with the same issues as other young persons around the world, but they are also socialized by a culture that is conducive to increased levels of early and frequent sexual activity. The Jamaican culture promotes early sexual activity and multiple partnerships for males, especially among adolescents and young adults. The adoption of multiple partnerships increases the likelihood of both primary and secondary exposure to STD, including HIV infection. Multiple partnerships, along with high rates of STD, especially untreated cases, and low rates of consistent condom use, as shown in the current study, point to a critical need for innovative programs that address the cultural aspects of sexuality in the country and promote consistent condom use with all partners during every episode of sexual intercourse.
Although many of the study findings are consistent with those of previous research examining Jamaicans and other populations, it is important to note the limitations of this study that may have an impact on the findings. Whereas the Reproductive Health Survey involved a national probability sample with response rates in excess of 90%, oversampling was used in smaller health regions. This resulted in a sample that had a significantly larger proportion of rural residents than exists in the national population, according to the most recent published census data. 41 Since rural residents were disproportionately represented in the sample, the generalizability of the results may be limited.
Another limitation was the use of secondary survey data, which inhibits the measures of STD symptoms and related behaviors. In addition, the use of self-reported data may threaten internal validity. The interview instrument had a number of sex-related items. As with all surveys of sensitive issues, such data are likely to contain some bias. Intentional misreporting, incomplete recall, and misunderstanding of survey questions could reduce both the reliability and the internal validity of the data. Especially with face-to-face interviews, individuals may be reluctant to fully disclose information of a sensitive nature such as symptoms and treatment of STD. 42
This study indicates that, despite education and awareness programs that have been in place for several years, a substantial proportion of young men in Jamaica continue to practice high-risk sexual behaviors. The probability of HIV transmission, as well as transmission of other STDs associated with even infrequent high-risk behaviors, remains significant. Although treatments exist for many STDs, it is important that prevention programs are implemented for those males who continue to engage in high-risk activities, especially those who do so in the presence of STD symptoms. Furthermore, since there is neither a cure nor a vaccine for HIV infection, only the adoption of safer sex practices can help curtail the spread of HIV infection as well as other STDs among the Jamaican population.
Prevention programs for HIV and STD transmission designed to target the Jamaican population must be innovative and inclusive. Strengthening the diagnosis and management of STDs among those who are sexually active and expanding and improving the quality of these prevention program could have a positive impact on decreasing transmission of HIV infection as well as other STDs. In addition, HIV/STD prevention program should tackle social, cultural, and economic factors that may fuel the transmission of STD. It is hoped that such program will be more effective in reaching those persons who continue to put themselves and others at risk for HIV infection and other STDs.
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