We described the results of a survey on HIV-related sexual behaviors among a population-based probability sample of young people on the island of Mauritius. Among unmarried young people aged 15–24 years, 30.9% of males and 9.7% of females reported a history of penetrative sexual intercourse. Of these sexually active people, behaviors that increase vulnerability to HIV infection were prevalent, e.g., having multiple partners (males), having sex without a condom, and having an older partner (females) [21
The proportion of sexually active unmarried youth in Mauritius, i.e., 30.9% of men and 9.7% of women, appears to be relatively low compared to that in other African countries. Data from 17 national surveys conducted in the past 5 years among young people aged 15–24 years from diverse countries in sub-Saharan Africa indicate that, on average, about 38% of men and 30% of women report having had premarital sex in the previous year [24
]. As prevalence of ever having had sex in these countries should be higher than that of sex in previous year, we can say that sexual activity of Mauritian youth is comparatively much lower than that of other African countries. In addition, when compared with data from the 1996 Mauritius Youth profile study, we did not observe a dramatic change in the proportion of sexually experienced unmarried youth. This relatively low prevalence of sexually active youth may be due at least in part to the predominance of religions with conservative sex norms and may partly explain how Mauritius has managed to maintain a stable low level of HIV infection in the 1990s, despite the devastating HIV epidemic in neighboring Africa.
Nevertheless, these findings do not leave room for complacency. Among sexually experienced Mauritian youths, 50.6% of male and 71.2% of female respondents did not use condoms at the last sexual encounter with a noncommercial partner. Although HIV infection risks may not be very high for young people as a whole, there certainly exist a group of youth who have unprotected sex and are vulnerable to HIV infection. Therefore, the HIV program for youth in Mauritius should aim to maintain the low prevalence of sexually active youth and to promote safe sexual behavior among those who are sexually active.
To achieve these goals, we need to identify the predictors of sexual behavior to effectively and efficiently target HIV prevention to this vulnerable subpopulation. We identified several factors related to the sexual behaviors of young people in Mauritius. For men, having ever worked and marijuana use were significantly associated with having ever had sex. In contrast, being out of school and drinking were associated with women's sexual experience. In addition, being Christian and visiting nightclubs were significantly associated with sexual experience in both sexes. Furthermore, among sexually experienced young people, the use of condom at first sex and exposure to an NGO's HIV program were significantly related to condom use at last sexual encounter. These findings suggest possible directions for effective youth HIV prevention programs in Mauritius. We grouped them into three possible approaches: (1) out-of school and in-school approaches, (2) nightclub and popular site approaches, and (3) religion and social status approaches.
Out-of-school and in-school approaches
Prevention efforts are needed outside the school system because the young people that were more sexually experienced were men who have ever worked or women who are not in school. Two channels currently exist in Mauritius to reach young people outside the school system: (1) peer educators trained by the AIDS unit of the Ministry of Health and (2) youth leaders attached to the youth centers of the Ministry of Youth and Sports. These resources should be reinforced to reach out-of-school youth to provide better reproductive health services. Furthermore, one of our most important findings was that exposure to an NGO program was associated with safer sexual behavior in young people. Because these activities are easily modifiable, a great opportunity may exist for the promotion of safer sex by reinforcing the activities of NGOs through peer educators or youth leaders.
At the same time, to maintain or reduce the number of out-of-school youth, enrollment in secondary and tertiary education should be promoted in a long-term perspective. In Mauritius, the enrollment ratio for primary school is 100%, but falls to 60% for secondary school, and 4.4% for post-secondary school [25
]; there is therefore room to promote secondary and tertiary education. By doing so, young people may delay their sexual debut by having greater access to information and skills, enhanced future orientation and aspirations, and by delaying exposure to the workplace where they encounter older people.
Reproductive health education needs to be promoted in schools because it is important for all young people, including the sexually inexperienced, to have the requisite knowledge and skills to use condoms beginning with their first sexual encounter. Our results indicate that condom nonuse at the last sexual encounter is significantly associated with condom nonuse at the first sexual encounter, i.e., those who used a condom at their first sexual encounter were much more likely to report using a condom at their most recent sexual encounter. The same trends were found among adolescents from other parts of the world [26
]. These results suggest that HIV prevention programs emphasizing appropriate and consistent condom use should target young people before the onset of sexual activity. In schools, where most students are sexually inexperienced, information on the risks accompanying sexual behavior should be provided to all students so that they can make informed future decisions.
Nightclub and popular site approaches
Nightclub visitation was correlated with other variables assessing popular sensationseeking behavior, such as possession of a mobile phone, watching pornographic films, alcohol intake, and marijuana use, in bivariate analysis. Although only nightclub visitation was significantly associated with sexual behavior in both men and women in multivariate analyses, the effects of these other items should be considered in the HIV prevention program. Media campaigns using various channels are potentially one of the most effective approaches to convey HIV prevention messages to these young people who seek out and are exposed to risks. As suggested in previous studies, role model stories printed in youth-attracting flyers may be a useful means to convey HIV prevention messages, even to hard-to-reach youths, because they can readily be distributed at popular sites where young people congregate [28
In addition, HIV prevention interventions, including education on the risks of drinking and drug use, could be explored in nightclubs because we identified nightclubs as an important place where sexually experienced young men and women congregate. The identification of specific access points will help the national AIDS control program to effectively use available resources for targeted interventions. Ford and Inman [30
] documented successful interventions to promote "safer sex" among young people in nightclubs in southwest England. The event was organized in a way that appeals to young people's sense of humor: competitions run by disc jockeys, free condoms, and "safer sex" materials. Although gaining the cooperation of venue owners may be challenging, such events could be considered in nightclubs in Mauritius to effectively reach young people with high risk factors for contracting HIV.
The effect of watching pornographic films should also be cautiously assessed because the bivariate analysis, but not logistic regression, showed this to be significantly associated with sexual experiences in young men. In fact, 70.6% of men, as compared to 12.9% of women, have reported ever having watched pornographic films. These films, most of which are from overseas, include unprotected sexual behaviors. A recent cohort study in the United States indicated that exposure to sexual content in the media accelerated adolescents' sexual activity and increased their risk of engaging in early sexual intercourse [31
]. Similarly, a study in China reported that younger students are more exposed to pornographic media than are older students [32
]. Taking these findings and the recent rapid increase in Internet use in Mauritius into account, attention should be given to trends related to the excessive exposure of young men to sexual media content. Video rental stores, of which there are many on the island, are potential intervention sites to address the watchers of pornographic films.
Religion and social status approaches
Christian youth reported more sexual experience than those in other religious groups. This may be partly related to their higher exposure to nightclubs, alcohol, and marijuana use because a relatively higher proportion of Christians live in urban areas compared to Muslims or Hindus. In this context, the popular site approaches (above) should be implemented, focusing on Christian youth.
Given disproportionate differences in sexual experience rates among religious groups, religious gatherings should also be considered as potential places for HIV prevention sessions to address sexual norms and reproductive health [33
]. Religious groups in Mauritius are still unwilling to promote condoms as a means of protection, and would rather stress abstinence and fidelity. Some religious people, however, are more involved in the fight against poverty, the commercial sex trade, and substance abuse, and through these related issues, they also deal with HIV/AIDS. Greater participation of religious leaders in HIV/AIDS programs may be facilitated through greater involvement of people living with HIV/AIDS (PLWHA), as suggested by work in Trinidad, where the religious profile is as diverse as in Mauritius [34
]. In Trinidad, personal interaction with PLWHA was positively associated with the involvement of religious leaders in HIV/AIDS initiatives.
Finally, it is needless to say that National AIDS Control program of Mauritius should swiftly act on HIV prevention for injecting drug users given the contemporary trends of HIV spread in this group. At the same time, with regard to young people, our findings suggest that early and focused programs are needed. Evidence from Cambodia indicates that young people are more willing to adopt safer behaviors than older people when provided with the appropriate services [35
]. Focused programs specifically targeting young people in general, as well as at-risk populations, such as sex workers and drug users, will have maximum impact and require the least resources when implemented at this early stage of the HIV epidemic. In particular, young women warrant special attention because the results indicate that women tended to have older sexual partners, which means that they may be more exposed to HIV than men [22
]. In Africa, young people, especially younger women, are the most seriously affected by HIV because of their social and biological vulnerability [36
]. Precautions are needed to protect younger women in Mauritius to avoid a situation similar to that on the African continent. The National AIDS Control Program of Mauritius should take every opportunity to intervene before the HIV epidemic escalates.
Our study is not without limitations, which include face-to-face interviews as the only modality of data collection. Although under-reporting might not have been completely avoided, the validity of the responses concerning sexual experience was assessed using a random response technique and considerable effort was made to put the respondents at ease, particularly for sensitive questions. However, self-report information may be subject to reporting errors and biases. Furthermore, the study was based on cross-sectional data for which the direction of causal relationships cannot be determined. Future studies need to assess the effectiveness of HIV prevention interventions in the context of young people's lives in Mauritius.