|Year : 2012 | Volume
| Issue : 2 | Page : 95-100
Alcohol Use and STI among men in India: Evidences from a national household survey
Arvind Pandey1, Ram Manohar Mishra2, Dandu CS Reddy3, Mariamma Thomas1, Damodar Sahu1, Deepak Bharadwaj1
1 National Institute of Medical Statistics, Indian Council of Medical Research, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Ex-NPO (HIV/AIDS), World Health Organization, New Delhi, India
2 HIV and AIDS Program, Population Council, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Ex-NPO (HIV/AIDS), World Health Organization, New Delhi, India
3 Ex-Prof. Head, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Ex-NPO (HIV/AIDS), World Health Organization, New Delhi, India
|Date of Submission||07-May-2010|
|Date of Acceptance||05-Jan-2012|
|Date of Web Publication||12-May-2012|
National Institute of Medical Statistics, Indian Council of Medical Research, Ansari Nagar, New Delhi - 110 029
| Abstract|| |
Background: Alcohol use has been found to correlate with risky sexual behavior as well as with sexually transmitted infections (STI) among populations with high-risk behavior in India. Objective: To examine the correlates of alcohol use and its association with STI among adult men in India. Materials and Methods: Data from a national representative large-scale household sample survey in the country were used. It included information on sociodemographic characteristics and alcohol use as a part of substance use. Clinical as well laboratory testing was done to ascertain the STI. Results: The overall STI prevalence among adult males was found to be 2.5% (95% confidence interval (CI): 1.9-3.1). Over 26% adult men were found to have been using alcohol in the study population. It was higher among men who were illiterate and unskilled industrial workers/drivers. The men who consumed alcohol had higher prevalence of STI (3.6%; 95% CI: 2.9-5.1) than those who did not consume alcohol (2.1%; 95% CI: 1.5-2.6). The degree of association between alcoholism and STI was slightly reduced after adjusting for various sociodemographic characteristics (adjusted odds ratio: 1.5; 95% CI: 0.9-2.3; P=0.06). Conclusions: The findings of present study suggest integrating alcohol risk reduction into STI/HIV prevention programmes.
Keywords: Alcohol use, human immunodeficiency virus, men in India, sexually transmitted infections
|How to cite this article:|
Pandey A, Mishra RM, Reddy DC, Thomas M, Sahu D, Bharadwaj D. Alcohol Use and STI among men in India: Evidences from a national household survey. Indian J Community Med 2012;37:95-100
|How to cite this URL:|
Pandey A, Mishra RM, Reddy DC, Thomas M, Sahu D, Bharadwaj D. Alcohol Use and STI among men in India: Evidences from a national household survey. Indian J Community Med [serial online] 2012 [cited 2013 May 26];37:95-100. Available from: http://www.ijcm.org.in/text.asp?2012/37/2/95/96094
| Introduction|| |
Studies on alcohol use behavior have drawn greater attention of social scientists and public health researchers in the recent past due to its hypothesized association with sexually transmitted infections (STI). The consistent relationship of alcoholism with risky sexual behavior as well as with STIs has been established by several studies in different parts of the world. ,,, In India, a survey of female sex workers (FSWs) and their clients conducted in 2006 by the National AIDS Control Organization (NACO) revealed that about 46% of the FSWs and 78% of the clients ever consumed alcohol. Of these, 11% of FSWs and 17% of clients consumed alcohol regularly before sex.  Another study conducted among long-distance truck drivers in the country found that truckers who consumed alcohol were about 2.7 times more likely to frequent FSWs than their counterparts.  Consumption of alcoholic beverages is shown to be associated with risky sexual behavior as well as with STI/HIV among clients of FSWs in Mumbai.  A study done among migrant FSWs as well as migrant male workers in 14 districts of four high HIV prevalent states in India concluded that more than half of the FSWs and their clients consumed alcohol prior to sex and alcohol use was independently associated with unprotected sex.  Alcohol use has also been concluded as an independent cofactor for HIV risk behavior among those being treated for psychiatric disease  as well as those addicted to injecting drug use. 
Alcohol consumption can enhance risky behavior in numerous ways, e.g., leading to more sexual partners, difficulty in remembering to use a condom, or being unable to use it correctly. Also, it may promote a social environment in which unprotected sex is more likely to occur. ,
The foregoing studies have investigated the possible associations between alcohol use and risk of acquiring STI including HIV among high-risk population including FSWs, clients, long distance truck drivers, migrant male workers, and injecting drug users. ,,,, Little is known about correlates of alcohol consumption and its association with STI/HIV among general adult men in the country. , It is in this light, the present paper has attempted to examine sociodemographic determinants of alcohol use and its association with the prevalence of STIs as measured by biological tests among adult men in India. It has used a nationally representative large-scale household sample survey to examine the associations.
| Materials and Methods|| |
We have used data from a community based survey undertaken by NACO in 2001 that was designed to provide estimate of STI prevalence among adult men and women in the age group 15-49 years residing in 28 States of India. The urban and rural samples within each state were drawn separately. The rural sample was selected in two stages, with the selection of primary sampling units (PSUs), which were villages, with probability proportional to population size (PPS) at the first stage, followed by the random selection of households within each PSU in the second stage. The procedure was similar in urban areas. Wards were divided into number of small segments of 150-175 households and two segments from each ward were selected systematically using PPS sampling procedure. Fifty men and women each were selected from each selected PSUs by adopting the systematic random sampling to interview them through a precoded questionnaire. Identified men and women were called in a health camp for clinical examinations and biological sample collection. After interview, respondents were diagnosed following syndromic approach of NACO and the STD syndromes were treated based on syndromic management. The laboratory specimens like vaginal swabs, urethral swabs, blood, Pap smear More Detailss, and urine samples were collected following standard techniques by the Skin and STD specialists and Gynecologists. A total of 14967 adults in the age-group (15-49) (7155 males and 7812 females) participated in the survey. More information about the survey design and implementation can be found in the published report of the survey. 
As the paper is focused on adult men, it uses data only from male participants in the survey. Further, the Behavioral Sentinel Surveillance conducted by NACO among clients of FSWs reveals that men start buying sex at age around 20 years.  Since alcoholism is hypothesized to increase the likelihood of getting STIs through risky sexual behavior; only males aged 20 and above have been selected for analysis to get true picture of association between alcoholism and STIs. Hence, hereafter a respondent refers to the male respondents in the aged 20 years or older.
Consumption of alcohol is taken as the use of alcoholic beverages at least once in past 3 months preceding the survey. The dependent measure in the paper is presence of STI, which is defined as presence (as found in the laboratory tests) of at least one of the following STIs - syphilis, herpes, herpes-2, HIV, trichomoniasis, chlamydia, and gonorrhea.
The educational attainment of respondents is subdivided into three categories: (i) illiterate (inability to either read and/or write); (ii) studied up to secondary (passed 10 th grade); and (iii) studied higher secondary and above (passed 12 th grade or completed graduate degree/higher studies). Similarly, occupation of respondent is categorized into following three subgroups: (i) unskilled industrial workers/drivers (unskilled workers, drivers, helpers/cleaners, or industrial laborers); (ii) skilled workers/businessmen (teachers, clerks, skilled workers, professionals, businessmen, or self-employed); (iii) Students/unemployed/social workers (students, unemployed, or social workers). Marital status of the respondent is categorized as currently married if the respondent was married at the time of survey and not currently married if respondent is not married at that time.
Discriminate analysis is used to examine the association between alcohol consumption and background characteristics of the respondents, and also to understand linkages of the STI prevalence across the various sociodemographic characteristics among all respondents as well as among consumers of alcohol. Differences in the percentages between the categories are tested using 95% confidence intervals. Logistic regression models are estimated to examine the independent correlates of alcohol use (outcome variable: Alcohol use in past 3 months) and the adjusted effect of consuming alcohol on presence of any STI (outcome variable: Presence of any STI at the time of survey).
Sampling weights (W i) are calculated for drawing valid conclusions from the sampled data. The calculations of weights are done as follows:
n i= Population size of the ith PSU;
N i = Total population size (sum of n i);
c = number of selected PSU;
c i = Number of completed interviews from ith PSU;
E i = Number of eligible respondents from ith PSU;
r i = Response rate of ith PSU and it was calculated as (c i/ a i); a i being the total number of respondents approached for the interview in the ith PSU. Statistical package Stata (version 9.0) has been used to analyze the weighted data.
| Results|| |
[Table 1] presents alcohol use among the men by their sociodemographic characteristics. The alcohol consumption is found to be positively correlated with the age of the respondents. The percentage of men consuming alcohol decreased with increase in the education (illiterate: 32.1%, 95% CI (27.4-37.1); up to secondary: 26.4%, 95% CI (22.9-73.1); higher secondary and above: 18.8%, 95% CI (15.7-22.5)). Alcohol consumption is significantly higher (27.7%, 95% CI (24.3-31.2)) among currently married respondents than their counterparts (18.8%, 95% CI (14.8-23.6)). Occupation is also found to be associated with the alcohol use. It is highest among unskilled industrial workers/drivers (28.5%, 95% CI (24.7-32.7)) and lowest among students/unemployed/social workers (17.1%, 95% CI (13.0-23.9)). Alcohol use is not found to be associated with place of residence, whereas it was significantly associated with religion of the respondents. Drinking alcoholic beverages is significantly higher among respondents, following other religions (35.0%, 95% CI (27.3-43.7) and among Hindus (28.4%, 95% CI (24.8-32.3)) than that among Muslims (10.1%, 95% CI (5.5-17.5)).
|Table 1: Percentage distribution of respondent who consumed alcohol in past 3 months preceding the survey by selected sociodemographic characteristics|
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[Table 2] provides prevalence of STIs among all respondents and alcohol users by their background characteristics. Overall STI prevalence among all respondents is found to be 2.5% (95% CI (1.9-3.1)). STI prevalence is significantly higher among alcohol users (3.6%, 95% CI (2.9-5.1)) than that among nonalcoholic respondents (2.1%, 95% CI (1.5-2.6)). Illiterate men are found to have significantly higher STI prevalence (3.7%, 95% CI (2.9-5.3)) than that among those educated till secondary and above (1.7%, 95% CI (0.8-2.9)). Among all respondents taken together the STI prevalence vary across different categories of age, occupation and religion. STI prevalence is higher among respondents who are older, unskilled industrial workers/drivers and non-Muslims. However, the differences in STI prevalence across these categories could not reach at statistical significance. Similar pattern of associations between background characteristics and STI prevalence is observed among alcohol users [Table 2].
|Table 2: STI prevalence (%) among respondents by alcohol use and selected socio-demographic characteristics|
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[Table 3] shows the adjusted odds ratios (AORs) of alcohol consumption and having STI derived from logistic regression analyses. It can be seen that current age, education, occupation, and religion of the respondents are significantly associated with the odds of alcohol consumption. Men of the age group 26-30 and 31-35 are, respectively, 1.4 (P=0.01) and 1.3 (P=0.04) times more likely to consume alcohol than younger respondents of the age group 20-25. Similarly, illiterate men are more likely to consume alcoholic beverages as compared to those educated till secondary and above (AOR: 1.8, 95% CI (1.4-2.3), P<0.00). Occupation is also found to be associated with the alcohol consumption as both unskilled industrial workers/drivers as well as skilled workers/businessmen are significantly more likely to consume alcohol than students/unemployed/social workers (unskilled industrial workers/drivers - AOR: 1.6, 95% CI (1.1-2.3), P=0.02; skilled workers/businessmen - AOR: 1.7, 95% CI (1.3-2.4), P=0.01). A significant higher odds of alcohol consumption is found for men following other religion (AOR: 2.7, 95% CI (1.7-4.3), P=0.01) and Hindus (AOR: 2.1, 95% CI (1.1-3.2), P=0.03) as compared to Muslims.
It is evident from the [Table 3] that after adjusting for various sociodemographic characteristics of the respondents, the degree of association between consumption of alcohol and presence of STI is slightly reduced (AOR: 1.5, 95% CI (0.9-2.3), P=0.06). Similarly, men grouped in the category of other religions are found to be at more risk of getting STI than Muslims (AOR: 1.9, 95% CI (0.8-7.5), P=0.07). Education continued to have a significant bearing on likelihood of having STI as illiterate respondents are more likely to have STI than those educated till secondary or more (AOR: 2.1, 95% CI (1.1-3.7), P=0.01). Other sociodemographic characteristics included in the analysis do not exhibit any significant association with odds of having any STI.
| Discussion|| |
The paper provides an empirical evidence of the prevalence of alcohol use and its association with STI among adult men in India. The prevalence of alcohol use in the present study is consistent with earlier studies though small-scale conducted in the country.  Though alcohol consumption increases with age, it is substantial even among young adults less than 25 years of age. The present study supports the findings from an epidemiological investigation conducted in the rural areas of Rajasthan which demonstrated that alcohol consumption was more common among men who were married and less educated.  The higher prevalence of alcohol use among unskilled industrial and transport workers as compared to their counterparts may be due to the belief that alcohol use furnishes the stamina necessary for hard physical labor.  The causal factors for the differences in alcohol consumption could not be examined as information on type and quantity of alcohol use has not been collected in the survey. Nonetheless this study confirms higher alcohol consumption among illiterate, married, unskilled and poor people of India.
The STI prevalence is found to be higher among those men who consume alcohol than their counterpart irrespective of their sociodemographic status. Though no information on risky sexual behavior has been collected in the survey, the increased STI prevalence among those who consume alcohol in the study is suggestive of the risky sexual practices under influence of alcohol among men in the country. The findings corroborate earlier small-scale studies carried out in low socioeconomic communities of Mumbai, which have shown a significant association between frequency, quantity, and types of alcoholic drinks with risky sexual behavior and presence of STIs among adult men. , It may be noted that the present study has not analyzed separately the viral and bacterial STIs because of small number of observations for each type of STI. Hence, in spite of such limitations as above about the availability of data to construct the pathways through which alcohol mediate with increased STI prevalence, the present study provides observed evidences that alcohol use is critically positively associated with the risk of acquiring STI even among so called low-risk general men in the country. This clearly suggests that prevention programmes need to recognize that alcohol use is likely to influence the ability to practice safer sex and hence there is a need to integrate alcohol risk reduction into STI/HIV prevention programmes in the country.
| Acknowledgment|| |
Authors would like to thank the anonymous reviewers for their comments to revise the manuscript of the paper. The study has used the data collected under a community based survey on prevalence of sexually transmitted diseases in urban and rural areas of India undertaken by NACO with the support from WHO.
| References|| |
|1.||Cooper ML, Orcutt HK. Alcohol use, condom use and partner type among heterosexual adolescents and young adults. J Stud Alcohol 2000;61:413-9. |
|2.||Fritz KE, Woelk GB, Bassett MT, McFarland WC, Routh JA, Tobaiwa O, et al. The association between alcohol use, sexual risk behavior, and HIV infection among men attending beerhalls in Harare, Zimbabwe. AIDS Behav 2002;6:221-8. |
|3.||Cook RL, Clark DB. Is there an association between alcohol consumption and sexually transmitted diseases? A systematic review. Sex Transm Dis 2005;32:156-64. |
|4.||Standerwick K, Davies C, Tucker L, Sheron N. Binge drinking, sexual behavior and sexually transmitted infection in the UK. Int J STD AIDS 2007;18:810-3. |
|5.||National AIDS Control Organization. National Baseline High Risk and Bridge Population Behavioural Surveillance Survey-2006, Part II: FSW and Their Clients. New Delhi: Ministry of Health, Government of India; 2006. |
|6.||Chaturvedi S, Singh Z, Banerjee A, Khera A, Joshi RK, Dhrubajoyti D. Sexual behavior among long distance truck drivers. Indian J Community Med 2006;31:153-6. |
|7.||Madhivanan P, Hernandez A, Gogate A, Stein E, Gregorich S, Setia M, et al. Alcohol use by men is a risk factor for the acquisition of sexually transmitted infections and human immunodeficiency virus from female sex workers in Mumbai, India. Sex Transm Dis 2005;32:685-90. |
|8.||Verma RK, Saggurti N, Singh AK, Swain SN. Alcohol and sexual risk behavior among migrant female sex workers and male workers in districts with high in-migration from four high HIV prevalence states in India. AIDS Behav 2010;14 Suppl 1:S31-9. |
|9.||Chandra PS, Carey MP, Carey KB, Prasada Rao PS, Jairam KR, Thomas T. HIV risk behaviour among psychiatric inpatients: Results from a hospital-wide screening study in southern India. Int J STD AIDS 2003;14:532-8. |
|10.||Kumar MS, Mudaliar S, Thyagarajan SP, Kumar S, Selvanayagam A, Daniels D. Rapid assessment and response to injecting drug use in Madras, south India. Int J Drug Policy 2000;11:83-98. |
|11.||Halphen-Felsher BL, Millstein SG, Ellen JM. Relationship of alcohol use and risky sexual behavior: A review and analysis of findings. J Adolesc Health 1996;19:331-6. |
|12.||Saggurti N, Schensul SL, Singh R. Alcohol use, sexual risk behavior and STIs among married men in Mumbai, India. AIDS Behav 2010;14 Suppl 1:S40-7. |
|13.||Singh SK, Schensul JJ, Gupta K, Maharana B, Kremelberg D, Berg M. Determinants of alcohol use, risky sexual behavior and sexual health problems among men in low income communities of Mumbai, India. AIDS Behav 2010;14 Suppl 1:S48-60. |
|14.||National Institute of Medical Statistics and National AIDS Control Organization: Community based survey on prevalence of sexually transmitted diseases in urban and rural areas of India. New Delhi: National Institute of Medical Statistics and National AIDS Control Organization; 2005. |
|15.||Issac M. India. In: Grant M, editor. Alcohol and Emerging Markets: Patterns, Problems, and Responses. Philadelphia: Brunner/Mazel, 1998. p. 145-75. |
|16.||Sundaram KR, Mohan D, Advani GB, Sharma HK, Bajaj JS. Alcohol abuse in a rural community in India. Part I: Epidemiological study. Drug Alcohol Depend 1984;14:27-36. |
[Table 1], [Table 2], [Table 3]