An analysis of social, behavioural and biomedical risk factors of adolescents and youth clients of female sex workers: Implications for STI/HIV/AIDS interventions in Bangladesh

The issue. Adolescents and youth (aged 15 to 24 years) constitute one-third of the total population of Bangladesh (43/129.2 million), and many are sexually active and at risk of contracting STIs and HIV/AIDS. Studies have shown prevalence of sexual risk behaviours, and premarital and extramarital sex is common. There is limited data however on the youth who are involved in risky sexual behaviour: information on sexual risk behaviour and practices, condom use, STI symptoms and the STI disease burden are essential for designing successful HIV intervention programmes. A study was conducted among young clients who visited hotels in Dhaka city to buy sex from female sex workers (FSWs), to generate knowledge on risk behaviour and practices.

The research. A total of 1013 youth (aged 15 to 24 years) visiting hotels to buy sex were enrolled in the study between September 2005 and February 2006. The study was conducted in 9 hotels (6 hotels with FHI-funded HIV intervention programmes and 3 hotels without such a programme) in Dhaka, Bangladesh, using both qualitative and quantitative methods. Eighty per cent of the sample was from intervention hotels and twenty percent from non-intervention hotels. A sub-sample of 53 young clients was purposively selected for in-depth interviews and 5 young clients and hotel staff were selected for key informant interviews.

Key knowledge

Sexual risk behaviour and practices. Among the enrolled youth around two thirds were aged 21 years or more, one sixth were married and around two thirds had high school or college education (12 years of completed school). Approximately half of them had their first sexual exposure before the age of 18. Qualitative data shows that some of the clients started sexual relations as early as 11-14 years of age. FSWs were the single most common sex partners in such exposures. More than 80% of the respondents reported that their first sexual exposure was influenced by peers/friends and peers/friends accompanied them in such exposures. Approximately one third reported buying oral sex along with vaginal sex and 10% reported buying anal sex along with vaginal sex. More than one third of the respondents reported having had group sex with FSWs.

Condom use. Around 18% of the young people reported that they had never used a condom and 15% reported that they always used condoms. Condom use was around 60% in the prior 5 sexual episodes with FSWs. Ninety percent of the young people in intervention hotels reported having received condoms from the hotels (compared to around 80% in non-intervention hotels). Around 20% of the young people in the survey and in-depth interviews reported having a non-commercial female sex partner, and almost all survey respondents reported having sex with non-commercial partners during the last year.

Both qualitative and quantitative data shows that ‘last-time condom use’ with a non-commercial sex partner was only 20%. More than half of the youth thought that it gives less satisfaction. In-depth interviews explored factors linked to the likelihood of condom use, like the trust of a sex partner, cleanliness, status, and negotiation skills.

HIV/AIDS knowledge. The most common mode of transmission of HIV/AIDS cited by the respondents was ‘sex without a condom’ (52.2%) but only 1.5% could name ‘unprotected sex with HIV-infected person’ as another mode of transmission. One quarter of the youth couldn’t name any route of HIV/AIDS transmission and had no HIV prevention knowledge. Using condoms during sex was the most cited way (59.6%) of preventing HIV/AIDS infection.

Both the survey and in-depth interview data showed prevalent misconceptions amongst young clients:

· more than one-third believed HIV can be spread by coughing or sneezing,

· 72% believed HIV can be spread through sharing food or water, and

· 79% believed washing his/her genitals after sex could prevent HIV transmission.

More than half of the respondents had not heard about STIs and only one-third could name the most common, syphilis. Sex without condoms was the most frequently cited mode of STI transmission (40.5%), however around 35% of respondents could not name any mode. Condom use was the most cited way to prevent STIs (48.7%). More than one-third of youth clients did not know any means of STI prevention and 80% had no knowledge about male STI symptoms.

STI disease burden. Twenty percent of the youth reported symptoms suggestive of STI in the last year and of these, more than half did not seek any health care. Of those who did seek care, only 15.3% had visited a doctor and 3.7% had visited a hospital/clinic. Laboratory testing found more than 10% of surveyed youth had at least one STI (2.2% had gonorrhoea,3.9% had C. trachomatis, 5.8% T. vaginalis, 12.9% had herpes simplex virus 2, and 1% had active syphilis).

Risk perception. Around 60% and 65% of the respondents reported that they perceived risk for STI and HIV infection respectively. However, the basis for such risk assessment was not due to irregular condom use but perceived risk of visiting sex workers.

Pornography. Almost all youth reported exposure to pornography, with more than 98% reporting such exposure in the last six months. In-depth interviews revealed that after watching pornographic films many respondents were heavily influenced to visit sex workers. Friends were the main source of pornographic materials, and more than 85% of respondents reported that they had learned about oral and anal sex through pornography. Qualitative data showed that types of sex act and sexual preferences were often linked with respondents’ perceived beliefs about mode of transmission of sexual infections.

Visiting hotel sex workers. Qualitative data highlighted some reasons for visiting FSWs. Some youth believed that wet dreams and masturbation were harmful to health and were influenced by peers to have regular sex to control them. Others reported that they had first visited FSWs to prove their masculinity, but then became habituated. Married respondents mentioned that they visited FSWs as a result of living apart from their wives, marital disharmony, or dissatisfaction in their sexual relationship.

Key messages. Clients have been identified as bridging population for the HIV/AIDS epidemic Bangladesh. Around half of them visit FSWs at least once in a month. They have high rates of STI and low STI care-seeking behaviour. Although they have knowledge about HIV/AIDS, their condom use is low.

Youth friendly health services need to be strengthened to offer STI management and STI/HIV counselling services targeted to youth. Appropriate strategies for intervention among young clients of sex workers need to be implemented. Different strategies targeting both female sex workers and clients need to be tested. For these types of combined strategies, the involvement of gatekeepers (particularly hotel management) is essential.

Further information.

GFATM Bangladesh

National AIDS/STD Programme (Bangladesh)

This study was a collaboration between Laboratory Sciences Division, Health System and Infectious Diseases Division, Public Health Sciences Division of ICDDR,B, Family Health International, Bangladesh Office and Bangladesh Women’s Health Coalition.

Click here to view or download Youth_Clients.pdf Size: 143.8 KB