Abstract
Aims
To establish the prevalence of intoxication before sex and its association with risky sexual behavior.
Design
The data were from the 2006 Uganda Demographic and Health Survey which had been designed for a cross-sectional descriptive study.
Setting
The study covered the whole country-Uganda.
Participants
The respondents were 6,253 women and 1,804 men who had ever had sex.
Measurements
The key independent variable was intoxication before last sexual intercourse while the major outcome variables were condom use and sex with non-regular partners. Weighted prevalence of intoxication was computed and multivariable logistic regression was applied to assess the independent association of intoxication with risky sexual behavior.
Findings
Twelve percent of men and 16% of women reported having been intoxicated before last sexual intercourse. Of the women who reported intoxication before last sexual intercourse, 78% said it was their partners who were intoxicated. Of the men who reported intoxication, 83% said it was they themselves who were intoxicated. Intoxication of the men was associated with having sex with non-regular partners (OR=1.78, 95%CI: 1.04-3.03) and having unprotected sex (OR=1.71, 95%CI: 1.07-2.73). Women who were intoxicated were less likely to have been with non-regular partners (OR=0.55, 95%CI: 0.32-0.95). The women whose partners were intoxicated before last sexual intercourse were more likely to report having had unprotected sex (OR=1.55, 95%CI: 1.12-2.15).
Conclusion
HIV prevention mechanisms should address intoxication before sex. More effort is needed to find ways of helping women avoid unprotected sex with intoxicated partners.
Keywords: HIV, risky sexual behavior, intoxication, alcohol use, sexual partners
Introduction
Engaging in sexual behaviors under the influence of alcohol can impair judgment, compromise power relations, and increase likelihood of risky sexual behavior.1 The situation is made worse with intoxication since in this state self control and executive functions are impeded. Intoxication is a major aspect of harmful use of alcohol which is defined as a pattern of alcohol use that causes damage to health and often includes adverse social consequences.2 According to World Health Organization (WHO) harmful use of alcohol has serious effect on public health and is considered to be one of the main risk factors for poor health globally.3 Harmful use of alcohol is also a major risk factor for HIV and other sexually transmitted infections and research investigating this and other risk factors is a public health priority.4-5 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) acknowledges the importance considering alcohol misuse in order to develop comprehensive HIV prevention strategies.6
Prevalence of intoxication before sexual activity was found to be more prevalent among the young individuals than older people in United Kingdom. A survey conducted among individuals born between 1980-1984, found that 6.4% were intoxicated at first sexual encounter compared to 2.5% among those born 1946-1949.7 A study carried out in Bulawayo, Zimbabwe found that a half of sex workers interviewed said their clients were intoxicated during the most recent sexual encounter.8 In Tuvalu, a study of young people aged 15-24 found out that 19% of men and 1% of women had sex while being intoxicated in the previous 12 months.9
Many studies have found a strong relationship between alcohol consumption and risky sexual behaviour. A study carried out among HIV positive women in the USA found a strong association between alcohol use and non-use of condoms.10 Another study in Spain found a strong relationship between alcohol consumption and risky behaviour for HIV.11Kalichman et al. reviewed 33 studies about alcohol use and risky sexual behaviour in Sub-Saharan Africa and concluded that alcohol use at all and more especially drinking high quantities of it were significantly associated with risky sexual behaviour and risk of HIV infection.12 A study among persons involved in national service in Nigeria found a strong association between intoxication and risky sexual behaviour,13 and another study in the UK reported having sex with non-regular partners among those who drank alcohol. A review of the above studies and others shows that most of the studies on alcohol use and risky sexual behaviour are based on small samples, focus on special groups, and use general alcohol use and risky behaviour measures, and are generally fewer in developing countries.
A recent review of alcohol and risky sexual behaviour studies categorises them into three groups, namely, global association, situational overlap and event level studies.5 The global association studies assume that an individual who engages in a risky sexual behaviour is likely to engage in another14. Global association studies show that heavy alcohol consumption is associated with increased risk of multiple or casual sexual partners and use of unprotected sex.5 Situation overlap studies focus on idea that an individual who consumes alcohol in a specific situation is more likely to engage in risky behaviour in that situation. Situation overlap studies show that men's alcohol consumption and that of their partners results in increased likelihood of unprotected sex while for women only partner consumption of alcohol was associated with same risk.15-16 Event level studies on the other hand carry out an in-depth examination of a specific behaviour occurring on specific occasion and are considered more precise than the global association and situational analysis studies.5, 17 However, few event level studies have been conducted in Sub-Saharan Africa.5 Key findings from event level studies show that alcohol use is significantly associated with unprotected sex and that the odds of engaging in unprotected sex were highest when male partner had been drinking.18
Heavy drinking or intoxication and HIV risky sexual behaviour studies have shown similar association as general alcohol use and risky behaviour. A study in the USA found that the number of sex partners reported by respondents was correlated with the frequency of alcohol use (p = 0.003), while in another study it is the quantity of alcohol consumption that was correlated with two indicators of risky sexual behaviour: having multiple sexual partners (p< .0001) and having sexual intercourse without a condom (p < 0.001).19 A recent study in the state of Goa, India found that after controlling for four demographic factors, volume of consumption and, in separate models frequency of heavy drinking, predicted sexual risk behaviour, with stronger associations seen for a measure capturing heavy drinking occasions than a usual quantity - usual frequency based measure20. This again suggests drinking pattern measures are likely to show stronger associations with these outcomes than simple volume measures. In some few studies there has been rather contradictory evidence on heavy alcohol consumption and risky sexual behaviour. One study in the USA found that whereas alcohol use increased sexual activity, intoxication did not.21
Few nationwide studies have been undertaken to establish the relationship between intoxication or alcohol use and risky sexual behaviour. A national study of the adolescents in Finland found that engagement in sexual activity increased with frequency of alcohol use. Frequent intoxication-related drinking increased the probability that the teenagers had experienced sexual intercourse and had unprotected sex. Further, the likelihood of engaging in unprotected sex and or having multiple sexual partners increased significantly with reports of intoxication.22
Worldwide there is still little research work done on intoxication prior to sexual activity and the paucity of such work is more evident in Sub-Saharan Africa. Most of the few studies conducted on intoxication before sex have been in well-defined social settings only23. While there has been evidence of association between alcohol consumption and risky sexual behaviour in Uganda, the data have been from localised sample surveys and were limited to alcohol consumption rather than hazardous drinking patterns including intoxication, or intoxication. Much less known is the relationship between intoxication before sexual activity and risky sexual behaviour. A study in Rakai found that 75% of participants in a population cohort study from 2006 to 2008 reported alcohol use before sex and alcohol use by either partner before sex was found to be associated with twice the risk of HIV transmission than reporting no such consumption.24
Uganda combines both a high HIV sero-prevalence and a high level of alcohol consumption.25In 2004 Uganda had the highest per capita alcohol consumption in the world with an average of 19.4 litres per capita.25 Despite the decline in 2011, Uganda still had the second highest per capita alcohol (11.93 litres) consumption in Africa and rated 28th in the world.26 Given such evidence, it is hypothesized that alcohol consumption may complicate and even undermine HIV prevention efforts. This paper investigates the prevalence of intoxication during sexual activity and associated risky behaviour in a nationwide sample. The risky behaviours examined in relation to this association are having multiple sexual partners and non-use of condoms.
Methods
The data were extracted from the Uganda Demographic and Health Survey (UDHS) conducted in 2006 which had 8,531 women and 2,503 men respondents. The overall response rate of the survey was 98%.1 The sample for the survey was drawn using a two stage cluster sampling where on first stage 368 clusters were randomly selected and then on second stage 25-30 households were randomly selected from each of the clusters. The data collection was through face to face interviews.1 The Primary Sampling Units (PSU) for the survey were clusters selected from 2002 national census while the Secondary Sampling Units (SSU) was households in the clusters. All women aged 15-49 and men aged 15-54 who were either permanent residents or visitors to the households were eligible for the interview. More details on the methods of the survey can be found in the UDHS report.1
Of the men and women surveyed in the UDHS, 7243 women and 2068 men had ever had sex but only 6206 women and 1810 men had had sex in the previous 12 months and responded to questions on alcohol use. The final weighted sample had 6253 women and 1804 men. A respondent was asked two questions about intoxication before last sexual intercourse. The questions were whether the respondent was intoxicated the last time he or she had sex and whether the respondent or his/her partner was intoxicated the last he or she had sex. Intoxication was measured based on the respondent's perception and recollection of her partner's and her own intoxication.
The data extracted from the UDHS data for the analysis included background characteristics and the variables on drinking before last sex, and several outcome measures. The background characteristics examined were geographical region, education level, marital status, type of residence, religion, occupation and age group. The key outcomes of interest were condom use during last sexual intercourse and having sexual intercourse with non-regular partner during the same event. The key independent variable was intoxication before last sexual intercourse.
The first stage in the analysis involved computing the weighted prevalence of intoxication before last sexual intercourse by background characteristics. The second level of analysis established the association of intoxication with risky sexual behaviour on bivariable analysis. Finally, we established the independent influence of alcohol consumption on risky behaviour using multi-variable logistic regression analysis to control for other risk factors. For different outcomes various covariates were adjusted to achieve the best model fit. Hosmer-lemeshow's goodness of fit is used due to large number of observations and relatively high number of covariate patterns.27-28 P-values higher than 0.05 are regarded as good for a good fit of the model since they show minimal difference between the fitted and observed probability of occurrence of outcome of interest28 which in this study are condom use and sex with non-regular partners.
Results
Sample characteristics
Of the 1804 men selected for this study 59% (1065) were aged less than 35 years. Six percent (109) did not have any formal education and 78% (1415) were married. The sample of the men was drawn from all four political regions of the country and Kampala capital city in proportion to the population size with the highest proportion (29%, n=520) from western region and the lowest from Kampala (9%, n=154). Fifty eight percent of the men (1037) were self employed in agriculture.
Like the men, most of the 6253 women selected for this study were of young or middle age as 72% (4502) were below 35 years. Slightly over a fifth of the women (1329) had not attained any formal education. Majority of them (82%, n=5129) were married. The women were selected from all four geographical regions of the country and Kampala capital city in proportion to the population size with the highest number from western region (27%, n= 1715) and the lowest number from Kampala (8%,n=490). More than two thirds (69%, n=4,104) of the women were self employed in agriculture.
Level of intoxication before sex
Nineteen percent (339) of the men and 24% (1488) of the women reported that they themselves or their partners used alcohol before last sexual intercourse. Twelve percent (216) of the men and 16% (1014) of the women said they were intoxicated or their partners were intoxicated before last sexual intercourse. The proportion that simply reported alcohol consumption without getting intoxicated was low (6.7% of men and 7.6% of women) (Table 1, Table 2, and Figure 1). Of the men that reported intoxication before last sexual intercourse 78% (9.4% of 12%) said it is them alone that were intoxicated while 83% (13.5% of 16%) of the women that reported intoxication said it was their partners who were intoxicated (Figure 2). Few respondents reported that both were intoxicated before last sexual intercourse (1.7% of men and 2.2% of women).
Table 1. Weighted prevalence of reported intoxication during previous sexual activity by background characteristics of men.
| Characteristics | Respondent alone Intoxicated (%) | Partner intoxicated (%) | Both intoxicated (%) | Any intoxicated (%) | Total respondents N |
|---|---|---|---|---|---|
| Region | |||||
| Central | 5.6 | 0.8 | 0.9 | 7.2 | 368 (20.4) |
| Kampala | 4.5 | 2.5 | 2.8 | 9.8 | 154 (8.5) |
| Eastern | 10.2 | 1.0 | 1.9 | 13.4 | 421 (23.3) |
| Northern | 11.3 | 1.1 | 2.5 | 14.9 | 342 (18.9) |
| Western | 11.5 | 0.2 | 1.4 | 13.1 | 520 (28.8) |
| Education | |||||
| None | 13.5 | 1.8 | 3.5 | 18.7 | 109 (6.0) |
| Primary | 10.4 | 0.8 | 2.1 | 13.2 | 1184 (65.6) |
| Secondary | 5.3 | 0.6 | 0.5 | 6.4 | 382 (21.2) |
| Higher | 9.3 | 1.6 | 0.5 | 11.4 | 130 (7.2) |
| Marital status | |||||
| Single | 2.6 | 0.3 | 1.5 | 4.4 | 292 (16.2) |
| Married | 10.4 | 0.8 | 1.6 | 12.9 | 1415 (78.5) |
| Widowed/separated | 14.7 | 3.9 | 3.6 | 22.2 | 97 (5.4) |
| Residence | |||||
| Urban | 6.9 | 2.1 | 1.8 | 10.8 | 282 (15.6) |
| Rural | 9.9 | 0.7 | 1.7 | 12.2 | 1521 (84.4) |
| Religion | |||||
| Catholic | 13.0 | 1.5 | 2.5 | 17.0 | 776 (43.0) |
| Protestant | 9.5 | 0.4 | 1.6 | 11.4 | 684 (37.9) |
| Muslim | 1.4 | 0.7 | 0.0 | 2.1 | 202 (11.2) |
| Other | 0.8 | 0.0 | 0.7 | 1.5 | 143 (7.9) |
| Occupation | |||||
| Profess/Clerical | 10.2 | 0.6 | 0.6 | 11.3 | 116 (6.4) |
| Agri/self employ | 9.7 | 0.7 | 1.8 | 12.3 | 1037 (57.5) |
| Sales | 7.6 | 1.7 | 2.5 | 11.8 | 140 (7.8) |
| Manual labour | 6.1 | 1.5 | 1.2 | 8.8 | 297 (16.5) |
| Others | 13.2 | 0.7 | 2.1 | 16.0 | 197 (10.9) |
| None | 11.6 | 0.0 | 0.0 | 11.6 | 17 (0.92) |
| Age group | |||||
| 15-24 | 2.9 | 0.9 | 0.6 | 4.4 | 408 (22.6) |
| 25-34 | 7.8 | 0.7 | 1.2 | 9.7 | 657 (36.4) |
| 35-44 | 13.2 | 1.4 | 2.1 | 16.7 | 489 (27.1) |
| 45-54 | 16.9 | 0.2 | 4.1 | 21.3 | 251 (13.9) |
| All | 9.4 | 0.9 | 1.7 | 12.0 | 1804 (100.0) |
Table 2. Weighted prevalence of reported intoxication during previous sexual activity by background characteristics of women.
| Characteristics | Respondent alone Intoxicated (%) | Partner intoxicated (%) | Both intoxicated (%) | Any intoxicated (%) | Total respondents n(%) |
|---|---|---|---|---|---|
| Region | |||||
| Central | 0.3 | 9.5 | 0.8 | 10.6 | 1237 (19.8) |
| Kampala | 0.5 | 7.0 | 1.9 | 9.4 | 490 (7.8) |
| Eastern | 0.6 | 14.1 | 2.3 | 17.0 | 1520 (24.3) |
| Northern | 0.7 | 19.9 | 5.5 | 26.1 | 1291 (20.7) |
| Western | 0.5 | 12.8 | 0.9 | 14.1 | 1714 (27.4) |
| Education | |||||
| None | 0.4 | 18.0 | 6.1 | 24.4 | 1329 (21.3) |
| Primary | 0.6 | 14.0 | 1.2 | 15.8 | 3729 (59.6) |
| Secondary | 0.5 | 6.9 | 1.2 | 8.6 | 934 (14.9) |
| Higher | 0.5 | 7.0 | 0.5 | 8.0 | 260 (4.2) |
| Marital status | |||||
| Single | 0.6 | 4.9 | 1.2 | 6.6 | 528 (8.5) |
| Married | 0.5 | 14.0 | 2.2 | 16.7 | 5129 (82.0) |
| Widowed /separated | 0.6 | 16.8 | 3.6 | 21.0 | 595 (9.5) |
| Residence | |||||
| Urban | 0.6 | 8.2 | 2.8 | 6.6 | 998 (16.0) |
| Rural | 0.5 | 14.5 | 2.1 | 16.7 | 5254 (84.0) |
| Religion | |||||
| Catholic | 0.5 | 16.2 | 3.6 | 20.4 | 2699 (43.1) |
| Protestant | 0.8 | 14.7 | 1.7 | 17.1 | 2131 (34.1) |
| Muslim | 0.1 | 4.1 | 0.4 | 4.7 | 728 (11.7) |
| Other | 0.2 | 8.9 | 0.5 | 9.6 | 694 (11.1) |
| Occupation | |||||
| Profess/Clerical | 0.3 | 7.8 | 8.7 | 8.4 | 232 (3.7) |
| Agri/self employ | 0.6 | 14.4 | 7.7 | 17.5 | 4,104 (65.6) |
| Sales | 0.5 | 10.1 | 8.2 | 12.6 | 549 (8.8) |
| Manual labour | 0.0 | 17.7 | 9.7 | 20.6 | 327 (5.2) |
| Others | 0.5 | 14.4 | 7.3 | 17.7 | 454 (7.3) |
| None | 0.2 | 9.2 | 5.2 | 10.0 | 587 (9.4) |
| Age group | |||||
| 15-24 | 0.5 | 8.0 | 0.9 | 9.5 | 2126 (34.0) |
| 25-34 | 0.6 | 15.2 | 2.2 | 18.0 | 2376 (38.0) |
| 35-44 | 0.4 | 18.4 | 3.8 | 22.5 | 1353 (21.6) |
| 45-49 | 0.4 | 16.1 | 4.1 | 20.6 | 397 (6.4) |
| All | 0.5 | 13.5 | 2.2 | 16.2 | 6,253 (100.0) |
Figure 1. Reported alcohol consumption before last sexual intercourse.
Figure 2. Pattern of intoxication before last sexual intercourse.
The level of intoxication before last sexual intercourse varied by region, education level, marital status, religion and age group of the respondents. Among men, the highest level of intoxication before last sexual intercourse was reported in the northern region (15%), among the uneducated (19%), the widowers/separated (22%), residents of rural areas (12%), Catholics (17%) and those aged 45-54 years (21%). Among the women, the highest level of intoxication before last sexual intercourse was also reported in Northern region (26%), among the uneducated (24%), the widowed/separated (21%), Catholics (20%), those employed in unskilled labour (21%) and those aged 35-44 (23%). Overall, the lowest levels of intoxication before last sexual intercourse were reported in central region, among those that had attained higher levels of education, the single, urban residents, Muslims, those engaged in manual labour, and the youngest age group.
Intoxication before sex and negative outcomes
There is an association between intoxication before last sexual intercourse and having had sexual intercourse with a non-regular partner and non use of condoms. Among men, those who were intoxicated before last sexual intercourse were more likely to have had sexual intercourse with non-regular partners (OR=1.78, 95%CI: 1.04-3.03) compared to those who were not intoxicated. Similarly, men who reported that their partners were intoxicated before last sexual intercourse were more likely to have had sex with non-regular sexual partners (OR=3.06, 95%CI: 1.39-6.72). Men who were intoxicated before last sexual intercourse were more likely to have had unprotected sex (OR=1.71, 95%CI: 1.07-2.73) but those whose partners were intoxicated were less likely to have unprotected sex (OR=0.42, 95%CI: 0.20-0.87) (Table 3). Therefore, intoxication of men is associated with having sex with non-regular sexual partners and non-use of condoms but when their partners are intoxicated they are more likely to use condoms.
Table 3. Reported intoxication before last sexual intercourse and its association with risky sexual behaviour among men.
| Factors | Had with non-regular partner- | Condom use before last sexual intercourse | ||
|---|---|---|---|---|
|
|
|
|||
| Model I with respondent intoxicated | Model II with partner intoxicated | Model I with respondent intoxicated | Model II with partner intoxicated | |
| Bivariate | ||||
| Respondent intoxicated (base=Not intoxicated) | 0.96 (0.60-1.56) | 1.92 (1.22-3.01)** | ||
| Partner intoxicated (base=Not intoxicated) | 2.19 (1.11-4.29)* | 0.81 (0.43-1.55) | ||
| Multivariable | ||||
| Respondent intoxicated (base=Not intoxicated) | 1.78 (1.04-3.03)* | 1.71 (1.07-2.73)* | ||
| Partner intoxicated (base=Not intoxicated) | 3.06 (1.39-6.72)** | 0.42 (0.20-0.87)* | ||
| Region | + | + | + | |
| Education | + | + | ||
| Marital status | ||||
| Residence | + | + | + | |
| Religion | + | + | + | |
| Occupation | + | + | + | + |
| Age group | + | + | + | |
| Goodnesss of fit-Lemeshow chi-sq &p-value | Chi-sq =12.3 p=0.14 | Chi-sq=12.4 p=0.14 | Chi-sq=8.2 P=0.42 | Chi-sq=4.22 P=0.84 |
factors included in the final model
p<0.05
p<0.01
p<0.001
Among women, those who were intoxicated before last sexual intercourse were less likely to have been with non-regular partners compared to those who were not intoxicated (OR=0.55, 95CI: 0.32-0.95). Similarly, those women who reported that their partners were intoxicated before last sexual intercourse were less likely to have been with non-regular partners (OR=0.76, 95CI: 0.60-0.96) compared to those who reported that their partners were not intoxicated before last sexual intercourse. On condom use, women who reported that they were intoxicated or their partners were intoxicated before last sexual intercourse were more likely to have unprotected sex compared to those who did not report being intoxicated or their partners intoxicated but this difference was only statistically significant when the partner was intoxicated (OR=1.55, 95%CI: 1.12-2.15) (Table 4). Therefore intoxication of women before last sexual intercourse was associated with having had sex with regular sexual partner while reported intoxication of their partners was associated with having had unprotected sex.
Table 4. Intoxication before last sexual intercourse and its association with risky sexual behaviour among women.
| Factors | Had last sexual intercourse with non-regular partner- | Had unprotected sex before last sexual intercourse | ||
|---|---|---|---|---|
|
|
|
|||
| Model I with respondent intoxicated | Model II with partner intoxicated | Model I with respondent intoxicated | Model II with partner intoxicated | |
| Bivariate | ||||
| Respondent intoxicated (base=Not intoxicated) | 0.45 (0.27-0.77)** | 1.52 (0.84-2.74) | ||
| Partner intoxicated (base=Not intoxicated) | 0.63 (0.51-0.79)*** | 2.06 (1.50-2.82)*** | ||
| Multivariable | ||||
| Respondent intoxicated (base=Not intoxicated) | 0.55 (0.32-0.95* | 1.19 (0.60-2.35) | ||
| Partner intoxicated (base=Not intoxicated) | 0.76 (0.60-0.96)* | 1.55 (1.12-2.15)** | ||
| Region | + | + | + | |
| Education | + | + | + | |
| Marital status | + | + | + | |
| Residence | + | + | + | + |
| Religion | + | + | + | + |
| Occupation | + | + | + | + |
| Age group | + | + | + | |
| Goodnesss of fit-Lemeshow chi-sq &p-value | Chi-sq =9.75p=0.28 | Chi-sq=9.48p=0.30 | Chi-sq=7.13P=0.52 | Chi-sq=1.34P=0.995 |
factors included in the final model
p<0.05
p<0.01
p<0.001
Discussion
These data have shown a high prevalence of alcohol use and intoxication before the last sexual intercourse in Uganda. The data have further shown that intoxication before sex is associated with HIV-risk behaviours of having sex with non-regular sexual partner and non-use of condom. Thus given the HIV prevalence estimated at 6.4%29 there is cause for concern over the high level of intoxication before sex.
The high level of both alcohol use and intoxication shows that many people could have reported sufficiently high quantities of alcohol intake in association with sexual behaviour as to lead to intoxication. Indeed, one may speculate that for many, their drinking may have been pursued in order to get intoxicated.
High prevalence of alcohol use before sex has also been reported by another study that was conducted in Rakai district in South Western Uganda30 and other regions.9 Elsewhere, another study in Mexico reported high levels of alcohol before sex (23%) among HIV-sero positive male clients of sex workers.31 Higher levels of intoxication (50%) have been reported among clients of sex workers in Zimbabwe.8
The demographic patterns of intoxication before sex were quite similar to the patterns of general alcohol consumption found in a Ugandan population study in 2003.32 As in the 2003 survey, the frequent or heavy alcohol consumption prevalence was highest in the northern region, and among the uneducated, the older people, unemployed, Catholics and rural residents. Higher levels of intoxication in the northern region could be attributed to the internal displacement and social instability at the time of the study. The northern part of Uganda experienced more than a decade of war and internal displacement of the population. The older people are able to afford to purchase alcohol and hence more likely to get intoxicated.
The finding that men were more likely to be intoxicated before sex than women is not surprising and agrees with many research findings. Men are more likely to drink and even more likely to be intoxicated before sex.33 They are more likely to take alcohol frequently and in larger amounts than women.32 A new study of women across Africa has confirmed a long held view that female drinking is not very common and attributes this to gender roles, religion and cultural tradition.34 Alcohol consumption by men is more accepted culturally.5 Furthermore, it is men who are more likely to have the economic means to buy alcohol.
The association between intoxication and risky sexual behaviour concurs with many other findings such as those carried out by Clark et al. in the USA,10 Castilla et al.11 in Spain and Sunmola et al. in Nigeria.13 Non-significance of association between intoxication of women and unprotected sex but significant relationship between intoxication of the sexual partners of the women and reported unprotected sex are in agreement with findings by Kalichman et al.16, 35
Gender differences in association of intoxication with risky sexual behaviour are evident in this study. Intoxication of the male respondents was associated with having sex with non-regular sexual partners and non use of condoms while intoxication of the female respondents was associated with having sex with regular sexual partners and it did not have a significant effect on condom use. Women whose partners were intoxicated before last sexual intercourse were less likely to report condom use while men whose partners were intoxicated were more likely to report condom use. This is consistent with other findings. A study in South Africa found that the odds for engaging in unprotected sex were highest when the male partner had been drinking.18
Conclusions and policy implications
The prevalence of intoxication before the last sexual intercourse is relatively high, especially among men. There is a strong association observed between intoxication before last sexual intercourse and unprotected sex and sex with non-regular partners. Women are unfairly affected. When their partners are intoxicated condoms are less likely to be used but when they are intoxicated their male partners are more likely to use condoms.
The implication that seems clear from these results is that interventions that aim to reduce HIV risk behaviour should include measures to reduce intoxication. More effort is also needed to protect women from having unprotected sex with intoxicated partners. Furthermore, Family planning efforts, STD/STI prevention and HIV counselling and testing programmes should integrally address alcohol use and heavy consumption and these behaviours in association with sexual intercourse. Our results emphasize that efforts to reduce alcohol intake and especially intoxication in association with sex should be central to these programmes' strategies.
Study limitations
The survey was cross-sectional and it is impossible to definitively place a causal relationship on the associations observed. One cannot with certainty determine whether it is alcohol consumption in association with sexual encounters which caused the risky behaviour or if instead the individuals with multiple risk tendencies also tend to consume alcohol more often and more often in association with sexual activity. These associations are thus best conceived of as interplay.
It is quite hard for some individuals to tell the difference between getting intoxicated and just having consumed alcohol. The question on whether one was intoxicated or just consumed alcohol is subjective and likely to be both attitudinally and socially determined.36 What some people see as having taken alcohol others see it as having become intoxicated and vice versa. A more objective measure or quantification of alcohol consumption would have been useful. But, these data still provide some good insights into the magnitude as well as relationship between alcohol consumption and HIV risk behaviour.
Acknowledgments
The data for this study was derived from the 2006 UDHS dataset. This work was presented in the Kampala KBS thematic meeting on 15th November 2010 which was funded by FORUT, World Health Organization, GENACIS and IOGT.
Funding sources: There was no funding received to produce the work but presentation in the Kampala KBS thematic meeting was possible through funding of the meeting by FORUT, World Health Organization, GENACIS and IOGT.
Source of funding: The data for this study were derived from the 2006 Uganda Demographic and Health Survey (UDHS) dataset which is given out freely by Uganda Bureau of Statistics and ORC Macro of Calverton, USA. No funding was received for the analysis but the work was presented in Kettil Brunn Society (KBS) thematic meeting in Kampala which was sponsored by FORUT, World Health Organization, GENACIS and IOGT.
Footnotes
Declaration of interests: There were no competing interests
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