|Year : 2013 | Volume
| Issue : 2 | Page : 88-94
Risky sexual behavior related to human immunodeficiency virus/acquired immunodeficiency syndrome among seasonal labor migrants: A cross-sectional study from far Western Region of Nepal
Dillee Prasad Paudel1, Rakesh Ayer2
1 Department of Public Health, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India
2 Nepal Health Research Council, Kathmandu, Nepal
|Date of Web Publication||26-Jul-2013|
Dillee Prasad Paudel
Department of Public Health, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Human immunodeficiency virus/acquired immunodeficiency syndrome is a global public health problem; enormously affecting the national economy, social development and human rights with posing a challenge to human civilization. Seasonal labor migrants are the most at risk population for HIV/AIDS and their risky sexual behaviors exacerbate its transmission. The aim of the study was to explore the HIV/AIDS related sexual behavior of migrant workers. Materials and Methods: A cross-sectional study was carried out among 372 migrant workers backing to Nepal from Banbasa border of India-Nepal during August-October 2010. Migrants having permanent residents of far western region, Nepal were individually contacted at the entry point of Nepal and interviewed in a confidential environment after obtaining informed consent. Data were analysed using the SPSS (16.0 version). Descriptive and inferencial statistics were applied considering P < 0.05 as significant. Results: Altogether, 372 male migrant workers (mean age± S.D.: 29.6 ± 1.9 years) were study participants. About 19.35% were illiterates 34.68% had primary education, 61.29% were married, and 74.20% were Hindus. About 53.22% were from schedule caste, and 41.94% had monthly income < 3000 Nepali rupees (NRs). About 45.77% were porter followed by 29.84%, 12.10% and 11.29% as construction workers, home servant, and hotel/supermarket helpers, respectively. Cent percent had any form of sexual contact and 45.96% had >3 sex partners. Most (82.25%) had vaginal sex and 43.54% reported the consistent use of condom. About 64.76% had sex after drinking alcohol. Age, education, monthly income and nature of works were significant with risky behaviors. Conclusion: Inconsistent condom use, multiple sexual partners and sex after drinking alcohol have a cumulative effect on the risk of HIV transmission.
Keywords: Human immunodeficiency virus/acquired immunodeficiency syndrome, migrant workers, risk behavior, sexual contact
|How to cite this article:|
Paudel DP, Ayer R. Risky sexual behavior related to human immunodeficiency virus/acquired immunodeficiency syndrome among seasonal labor migrants: A cross-sectional study from far Western Region of Nepal. Int J Health Allied Sci 2013;2:88-94
|How to cite this URL:|
Paudel DP, Ayer R. Risky sexual behavior related to human immunodeficiency virus/acquired immunodeficiency syndrome among seasonal labor migrants: A cross-sectional study from far Western Region of Nepal. Int J Health Allied Sci [serial online] 2013 [cited 2017 Dec 15];2:88-94. Available from: http://www.ijhas.in/text.asp?2013/2/2/88/115683
| Introduction|| |
Human immunodeficiency virus/acquired immunodeficiency syndrome is an emerging problem of the global community and human civilization. Though many efforts had been taken globally, it's devastating effects can be seen in many areas such as human productivity, public health, and human rights. Globally, by the end of 2009, 33.3 millions of people were affected by HIV; 30.8 million were adult population and 5.2% of them died due to AIDS. About 4.1 million people were affected only in South East Asia region.  Intravenous drug users, male having sex with male (MSM), female sex workers (FSWs), and migrant laborers/workers are at most risk population of HIV and AIDS. The possibility of transmission of HIV infection from these high-risk groups to the general population is a serious health concern.  Migrants are often a medically underserved population. Internal and international migration plays an important role in the spreading of HIV infection throughout the world. There are multiple concerns about the relationship between migration and HIV/AIDS. Separation from their spouses and adrift from the social bindings, many of these migrants are susceptible to unsafe sexual contact with FSWs, multiple sex partners, injecting drugs, increase in number of MSMs, unnatural mode of sexual intercourse and sexual contact with using alcohol at their working areas. 
About 0.6-1.3 million workers migrate annually from Nepal to different places of India especially, Uttaranchal, Maharashtra, Uttar Pradesh, and Delhi States to do labor work for a certain period (4-6 months) and back to Nepal via different transit points. High prevalence rates of STIs and HIV infection was found in such population (returnee migrant workers).  According to Nepal's 2007 United Nations General Assembly report, labor migrants make up 41.0% of the total known HIV infections in the country, followed by clients of sex workers (15.5%). Far western region of Nepal accounts for 16.0% of the total HIV cases; of which nearly three-quarter (74.0%) covered by migrant workers only. 
The issue of HIV and AIDS among seasonal migrants is developing as a severe public health problem and challenging to the national economy, social development and human rights as a whole by mutilating and soiled them. The main aim of this study was to explore the HIV and AIDS related, risky sexual behavior of returnees' migrant workers/labors in Nepal.
| Materials and Methods|| |
Descriptive cross-sectional study was carried out in the Mahendra Nagar-Banbasa border area of Far-Western Region (FWR) of Nepal. Banbasa is only the main entry/exit point to India and Nepal in this region. Hundreds of people from different parts of Nepal and India cross the border every day for trade and other working purpose. The study participants were the migrants having permanent resident in FWR and visited at least 2 times in India and stayed as a labor for a season (4-6 months/season) at each visit and back to Nepal during the period of August to October 2010. All eligible people; were individually screened at the entry point of Nepal with co-ordination and support of a leading social organization; Maiti Nepal.
The sample size was calculated by using the proportion based statistical formula; n = z 2 p (1-p)/d 2 with considering 5% absolute error and 95% confidence interval (CI) level. On the basis of inconsistent use of the condom rate (P = 33%) by the migrant workers in previous similar type of study, the minimum sample size was 339. Adding 10% non-response rate, the final sample size was 372. Systematic random sampling technique was applied to select the sample from screened migrant workers. The participation in the study was voluntary, and necessary informed consent was obtained. The participants were briefed about the aim and process of the study and privacy was fully maintained throughout the process by interviewing them in a confidential environment. Pretesting of the questionnaire was performed to check the consistency, outlier, and missing values before starting the final study. The questionnaire covered several aspects of risky sexual behaviors (RSB) related to HIV/AIDS and socio-demographic profile. Data were checked and re-checked and entered into the computer on the same day by using the statistical software SPSS (version-16). Both descriptive (percentage, mean, median, mode, range, and standard deviation) and inferential statistic (χ2 test) was applied to analyse the data. The sexual risk behavior was categorised in high-risk and low risk behavior on the basis of the sexual behaviors experienced by the workers during the staying in India and back to Nepal. The criterion for statistical significance was set at test value (P < 0.05). The analyzed data were presented in tables, graphs, charts and narrative description as per necessity.
| Results|| |
Socio demographic profile of the respondents
Altogether, 372 male migrant workers (mean age ± SD: 29.6 ± 1.9 years; range: 18-47 years) participated in the study, and the majority (29.84%) of the participants were in the age group 28-32 years followed by 25.81% in 33-37 years. Half (50.81%) of the participants were from primary and informal educational background whereas nearly (19.35%) were illiterate and 4.84% from secondary and higher. More than (61.29%) of the participants were married, and nearly three-quarters (74.20%) were from the Hindu religious background followed by; 21% Buddhist and 4.03% Christians and others. More or less 41.94% participant's monthly income was < 3000 NRs. and remaining other (58.06%) earned > 3000 NRs (3000-1000)/month. Nearly, three-quarter (70.17%) of participants had nuclear type of family structure and more than half (53.22%) were of scheduled caste. According to their nature of job during the staying in India; about 46.77% were porters followed by; 29.84% construction workers; 12.10% home servant and 11.29% hotel/supermarket helper as illustrating in [Table 1].
|Table 1: Distribution of respondents by sociodemographic characteristics (N=372)|
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Exposure to RSB
RSB of the participants had been identified by motivating them to response the quires related to the exposed sexual behaviors which have directly or indirectly link with transmission of HIV. The study showed that almost all; 372 (100.00%) participants had experience of sexual contact. Nearly, half (47.58%) had experienced during teen age (before their age of 19) while, only one-quarter (25.00%) had after the teen and remaining one-quarter could not recall the exact age of first intercourse. Cent percent of the participants had exposed with FSWs during their lifetime; among them more than half (54.04%) had contacted with 1-2 FSWs followed by 42.74% with 3-4 and 3.22% with more than four FSWs to fulfill their sexual desire. Most of the participants (82.25%) used only vaginal rout to do the sexual intercourse and remaining of the other (17.75%) used combine routs (vaginal as well as anal and oral). About more than ⅖ (43.55%) of the participants reported that they used condom during their each sexual intercourse with FSW. Among the condom user, only 57.4% used it consistently and rest of the other, neither used the condom nor used consistently who used. Most of the participants (91.94%) who used or didn't use the condom during the sexual intercourse with FSWs did not willing to use a condom during the sexual intercourse with their own wife/ves/regular partner/s. Less than one-tenth (8.06%) of the participants had experience of sexual exposure with their male partner (MSM) and cent percent of them never used the condom during anal sex. Majority of the participants (84.68%) reported that they drink alcohol before every sexual contact and nearly one-third (32.38%) of them were regular (daily) drunker as summarized in [Table 2].
Level of risky sexual behavior related to HIV
The level of risky sexual behavior was identified on the basis of consistent use of condom during sexual intercourse with their sex partner by considering other related risky sexual behaviors such as age at first intercourse, sexual exposure with FSW and MSM, frequency of coitus with inconsistent use of condom, numbering of sex partner, different routes of sexual intercourse and sexual intercourse after drinking alcohol. This study revealed that about three-quarter; 279 (75%) of the participants had exposed with high-risk sexual behavior initiating to HIV and AIDS as showing in [Table 3].
Factors associated with the level of risky behavioral pattern related to HIV/AIDS
Risk sexual behavior related to HIV/AIDS is a dependent phenomenon which is directly and indirectly affected by different socio-demographic factors [Table 4]. The study revealed that the level of sexual risk pattern for HIV transmission is depends on the age of the participants (χ2 = 10.49 at df = 1, P < 0.01), educational background of the participants (χ2 = 13.90 at df = 1, P < 0.001), religion (χ2 = 8.03 with Yates correction at df = 1, P < 0.02), monthly income of the respondent (χ2 = 19.07 at df = 1, P < 0.001) and nature of bonded by the participants. meanwhile, the level of risky sexual behavior is not significantly associated with the other demographic variables; marital status, type of family and ethnicity/cast of participants; (P > 0.05).
|Table 4: Association of risk behavior with different socio demographic variables|
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| Discussion|| |
RSB and associate socio-demographic profile of the participants is the most important numerators of this study. Socio demographic findings specially age, educational background, religious background, monthly income, and nature of works of the participants in this study have significantly associated (P < 0.05) with the risky sexual behavior practiced by them. All the participants were having the age range 18-47 years (Mean age: 29.6 ± 1.9) and nearly half of them were less than the mean age; which was consistent to the mean age (28.0 years) of the study subjects of Integrated Biological and Behavioral Surveillance IBBS survey, 2008 in Nepal,  and similar study in conducted in India.  Moreover, inconsistent with the similar study (median age of participants: 39; age range: 18-63 years) conducted in China. 
This study revealed that nearly (19.35%) of the participants were illiterate and about half (50.81%) had got primary education. The level of RSB for transmitting of HIV and other STIs is significantly (P < 0.001) associated with the level of education. Study in rural India showed that 57.6% returnee migrants exposed with risky sexual behavior which was poorly associated with education level of the participants accounting primary level (47.1%) illiterate (10.5%). 
The monthly income of the participants was also the Contributing factor for exposing towards the RSB. The study showed that the people having high income (>3000 NRs)/month were significantly high in exposure to RSB with compare to the people having the low (≤3000 NRs)/month income. The result of this study was consistent with other similar studies from Bangladesh and China. Study in Bangladesh showed; 91.00% of migrant workers having RSB were below the poverty line.  study in China showed 67.3% workers exposed with risky behavior had monthly income less than 3000 (P < 0.001). 
The study result showed that the pattern/nature of job is also significant risk factor initiating to follow the high-risk sexual behavior. Laborer/porter and construction worker had more exposure to the risky sexual activity (P < 0.01) as compare to other workers such as server in hotel/markets and domestic workers. When people have leisure time and no option of controlling measure (either self-control or external control) then they try to entertain through sexual activities, which initiate them to follow unsafe sexual behavior. This result was matching with a similar study conducted in Thailand among migrant workers from Myanmar,  showed that workers who worked in construction, factory workers, hotel and restaurants, tourist guides, tattooing and hair dressing were more likely to use addictive substance and exposed to risky sexual behavior than shop helpers, and housemate (P < 0.002). Study in Bangladesh among female migrant workers showed that most of the workers who exposed with sexual activities with their sex partner during their leisure time. 
Similarly, RSB is also significant at 2% level (P < 0.02) with the religious background of the participants while some other socio demographic variables showed contradictory results with compare to similar other studies. ,,, Marital status (unmarried vs. married), family type (nuclear vs. joint) and ethnicity/cast (higher vs. schedule) are not significantly associated with RSB.
Sexual behavior of participants is the major risk factors of transmitting HIV infected person to the healthy person. The study showed that more than 48% of the seasonal migrants had onset sexual activity within teen age (≤9 years). Study in rural India,  showed that most of the study participants had exposed with sexual intercourse in the age of 18.9 ± 2.5 years. Age at the onset of sexual intercourse and the high-risk sexual behavior are closely related the person practicing sexual activity earlier and can be considered as the significant indicator in assessing the risk of HIV infection.
Number of casual partners visited by the participants is also significant behavior for HIV transmission. This study revealed that nearly half (45.96%) had sexual intercourse with more than three casual partners (causal partner here refers to FSWs, female friends, girlfriends as reported by the seasonal migrants) during last 1 year period. Sexual contact with the multiple partners and FSWs increases the frequency of unsafe sexual contact. Study in India illustrated that 57.7% of migrant had ever contacted either with FSW or unpaid casual partner where as 17.7% exposed with more than three sexual partners. 
Consistency of the condom use is one of the major indicators used to measure the risk of HIV. The study revealed that around Ό of the participants used condom during sexual intercourse with a casual partner. Condom use correctly during each sexual intercourse is considered as a lone measure to get protected from HIV. The study findings showed that nearly three-quarter of the participants used condom inconsistently which can be attributed to the ignorance, low educational qualification, and free from the social bindings. The level of condom use among migrant men when visiting FSWs varies across different regions. Study among boatmen in Bangladesh showed, condom use was low at less than five percent.  Similar Study in Nepal showed, only 26.0% of returned migrant who had pre-marital or extra-marital sex used condom consistently.  Study in China showed that risky sexual behavior such as sex with a casual or commercial sex partner was associated with no stable partner; inconsistent use of condom; age <22 at first sex; higher coitus frequency; and having a positive attitude towards multiple sex partners. 
Consistency of the condom use reveals an interesting finding over here, when participants had sexual contact with casual partners in Nepal the consistency of the condom use increases up to 43% this can be attributed to the fear, identity of own place whereas the consistency of the condom use decreases while practicing to sexual contact in India. Consistency of the condom use when having sex with wife was found to be very low (8%). Many participants reported that there is no need to use a condom during sex with wife only in the case of birth spacing that poses a serious threat of HIV transmission to their spouse. Study from the rural South Carolina showed that 46% of the migrant workers had never used condoms during the sexual intercourse. It showed that there is a relatively high rate of HIV infection in these rural South Carolina migrant workers, whose behavior puts them at risk for HIV and other sexually transmitted infections STIs.  Study from rural India showed that 73.9% migrant workers used the condom consistently during the sexual intercourse with sex workers whereas the consistency of condom use decreased to 22.6% during the contact with casual unpaid partner. 
Mode of sexual contact is also the significant risk behavior for HIV transmission. This study revealed that most of the participants (82.25%) used only vaginal route to do the sexual intercourse while the rest of the other (17.75%) used combine routs (vaginal as well as anal and oral). About 8.0% of the participants reported to have anal sex with men without using condom that have more risk to HIV infection than other route.
| Conclusion|| |
Risky sexual behavior of migrant workers exerted as inconsistent condom use, multiple sexual partners, and sex after drinking alcohol have a cumulative effect on the risk of HIV transmission. HIV prevention interventions such as Behavior Change Communication and awareness on HIV/AIDS among the migrant workers need to focus on younger migrants who travel abroad for work.
| Acknowledgment|| |
Authors are thankful to study participants, social organizations and other personnel for their valuable support to complete this study.
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[Table 1], [Table 2], [Table 3], [Table 4]