Young Adults in Urban Pakistan; Barriers and Challenges for Improving Health Behaviors in the wake of the HIV/AIDS Epidemic

Abstract: Background: HIV/AIDS is spreading globally more specifically among the younger generation. The impact of HIV/AIDS on the youth cannot be underestimated. According to the UNAIDS report 2008; an estimated number of 33 million people around the globe were living with HIV in 2007, and overall, 2.0 million people died due to AIDS, compared with an estimated 1.7 million in 2001. The HIV/AIDS epidemic is most likely to affect health status, economic conditions and family situations. Unprotected sex with an infected partner, contact with infected blood, sharing of drug needles or syringes and mother to child transmission are the modes which cause HIV infection. Surveillance data of Sindh AIDS Control Program, Pakistan suggest that HIV infection is rapidly increasing among injecting drug users (IDUs) and had reached 9% in 2004-5 indicating that Pakistan has entered the concentrated epidemic stage for HIV/AIDS i.e. the HIV prevalence in high-risk subpopulations is 5% or higher. This poses a serious threat of a generalized epidemic especially among the younger population of Pakistan. The prevalence of HIV infection among female sex workers was minimal. Cultural and religious constraints in discussing reproductive health issues and lack of youth clinics further makes the younger generation more vulnerable to HIV/AIDS. Aim: The overall aim of this thesis is to explore and describe young adults knowledge and perceptions on sexual and reproductive health with special reference to HIV/AIDS, future gender roles and implications for health behaviors and prevention in Karachi, Pakistan. Methods: The studies were conducted in the city of Karachi, Pakistan, which is the largest city and the economic and commercial hub of Pakistan and comprises of people from all ethnic backgrounds. Karachi is divided into 18 towns based on administrative units. This project has used both quantitative (study I and II) and qualitative methods (study III and IV). A population-based, cross-sectional study of 1,650 young adults (male n=826) and (female, n=824) aged 17-21 years living in Karachi was conducted using a structured questionnaire (study I and II). A multi-stage cluster sampling design was used to collect data representative of the general population in an urban area in all 18 towns of Karachi. School/college dropouts and preliminary knowledge about STDs were assessed (Study I), further knowledge about HIV/AIDS was assessed (study II). Bivariate and multivariate analyses were performed separately for males and females. A qualitative exploratory study was carried out (study III and IV). Focus group discussions were used for data collection. Participants, both males and females aged 17-21 years were purposively chosen from three different social strata. Altogether, six FGDs (6-8 participants in each FGD) were conducted in the local language Urdu, two from each social stratum. Knowledge and perceptions of HIV/AIDS and family planning were explored (study III), the perception of future life prospects and gender roles were also discussed (study IV). Qualitative content analysis was applied to identify manifest and latent content. Results/findings: Study I revealed that females were twice as likely to dropout of school/college as males. The risk factors for school/college dropout for both males and females were migrant residential status, living in an extended family and low socio-economic status. Furthermore, females exhibited a higher level of awareness about STDs and HIV/AIDS than the males, irrespective of whether they had dropped out of school or not. While the males who dropped out were considerably less aware than those who remained at school, there was no such difference among females. Knowledge of HIV/AIDS was assessed in detail (study II), and it was found that out of 1,650 subjects, 24 per cent (n=390) reported that they had not heard of HIV/AIDS. Among the males, those with a poor HIV knowledge were younger (AOR=2.20; 95 per cent CI, 1.38, 3.49) and had less than six years of schooling (AOR=2.46; 1.29 4.68) with no access to computer at home (AOR=1.88; 1.06 3.34). Among the females, the risk factors for poor knowledge were young age (AOR=1.74; 1.22, 2.50), low socio-economic status (AOR=1.54; 1.06, 2.22), lack of enrolment at school/college (AOR= 1.61; 1.09, 2.39) and being unmarried (AOR=1.85; 1.05, 3.26). Knowledge and perceptions of HIV/AIDS and family planning was further explored (study III). The main theme that emerged from the focus group discussions was Need for multilevel strategies to combat the spread of HIV/AIDS and enhanced acceptance of family planning . A knowledge gap was revealed concerning HIV/AIDS and family planning among young males and females, who had to rely on media and peers for seeking information. Participants perceived that HIV/AIDS is incurable and carries a social stigma. Female participants pointed at the existence of societal discrimination against women with HIV/AIDS. The opposition of family planning from religious leaders was revealed. Exploring the perceptions of future life prospects and gender roles (study IV), the main theme that emerged from the focus group discussions was Expectations of young adults in a changing society is hampered by psychosocial and gender equality constraints . Not only did young males but young females too perceive that good education and a respectable job are obligatory for better life prospects. The major obstacles in this regard were lack of merit system and scarceness of jobs. The younger generation believes that both men and women should share household tasks. Gender inequality and the lower status of women in society were considered obstacles to development. Conclusion: Pakistani young adults having inadequate knowledge and awareness are vulnerable to the global HIV/AIDS epidemic. Both young men and women are well motivated to acquire good education and employment; and seem to belief in gender equality. Transition to better education and gender equality will result in new health related challenges, which emphasize that these young people should be equipped with proper knowledge about STDs and health related behaviors. Religious and cultural barriers to discuss reproductive health issues further deteriorate the situation. Nevertheless, as the prevalence of HIV/AIDS is still comparatively low, the epidemic has not yet enforced a general discussion on the importance of a well-informed younger generation.