This study provided the opportunity to look at HIV-related sexual risk behaviors among YHH aged 12-24, living on their own, in a rural area of Rwanda, Gikongoro district. The results show striking differences on many aspects with findings from the recent DHS in Rwanda with regard to youth and orphans [35
Knowledge of the "ABC" HIV/AIDS messages is very low among YHH with only 19.8% of youth being able to cite all three prevention measures. Use of condom was particularly less likely to be known among females than males (48.9% versus 65.7%). Knowledge of both use of condom and being faithful to one sexual partner was also very low at less than 20%. Although 85% of YHH seem to know a person who died of AIDS, the majority (68.9%) do not perceive themselves at risk of HIV infection. Half of respondents (50.7%) reported knowing a neighbor who had died of AIDS, reflecting the high HIV prevalence in the community. Results from the 2005 RDHS show a similar trend of HIV knowledge although figures are much higher; 51% of young women and 54% of young men age 15-24 were shown to have a comprehensive knowledge (Use of condom and limiting sexual intercourse to one faithful uninfected partner) of the means of prevention and transmission of HIV/AIDS. In addition, 79.5% of women and 88.4% of men knew that the risk of contracting HIV/AIDS can be limited by using condoms.
Among YHH in Gikongoro, 36.9% of males and 28.3% of females reported a history of penetrative sexual intercourse. Respondents in this population reported a very young age of sexual debut with 41% before the age 15; males being more likely to start earlier than females (50.4% versus 26.7%). The 2005 RDHS again shows similar ratios between males and females, but much lower percentages of early sexual intercourse in the DHS study with more frequency among men (14%) than women (5%).
While sexual activity is higher among YHH respondents compared to youth of the same age in the general population, the use of condoms is not common. Thirty-three percent reported having had at least one partner during the past twelve months with only 13.2% using condoms during the last sexual intercourse. In the 12 months preceding the 2005 RDHS, approximately 5% of never-married women age 15-24 had had sexual intercourse. Among these women, 25% used a condom at their last sexual intercourse. Among never-married men age 15 to 24, approximately 9% reported having had sexual intercourse in the past 12 months and, among these, 39% used a condom at their last sexual intercourse. Similarly, the use of condoms appeared not common at first intercourse in this study population. On average, only 8.3% reported the use of condoms at first sex in our study compared to 12% for men and 7% for women among youth age 15-24 in the DHS.
Obviously, these findings suggest that YHH in Gikongoro might be sexually vulnerable and at high risk of HIV infection and poor health outcomes. While the results indicate that YHH are not very sexually active (1.75 mean lifetime sexual partner, 0.45 mean sex partner last twelve months) as in other SSA settings, research shows that early sexual onset is associated with lowered condom use in subsequent relationships [7
], an increased risk of HIV infection [5
], and higher likelihood of unintended pregnancy [6
]. In fact, a sizable proportion of YHH respondents do not use condoms, had their first sexual intercourse at a very young age and with older partners, risk factors for HIV infection [27
]. In addition, transactional sex, a factor that may limit their ability to negotiate the use of condoms [28
], was reported by 10% of youth. Moreover, the lack of adult supervision and non condom use may have heightened risks of adverse reproductive health outcomes [37
], as 58.2% of sexual experienced females reported a pregnancy.
Although there may be various circumstances explaining early onset of sexual activity among YHH in Rwanda, poverty may be an important factor vis-à-vis survival. However, in this study, no association emerged between assets, number of meals per day used as proxy for socio-economic status and sexual onset. This finding is inconsistent with evidence from other studies showing that low wealth and economic hardship may contribute to the engagement of youth in sexual activity [12
]. It appears that the burden of HIV/AIDS and the loss of parents during the genocide impacts strongly on YHH. Poverty associated with lack of resources and the scarcity of land in an overpopulated country may increase youth's difficulty in meeting the needs of their siblings [38
]; 43.4% of YHH reported having only one meal per day. For some youth, prostitution and survival sex may serve as a means of obtaining basic needs [14
]. In fact, 7% of female respondents reported having received money or gifts for sex and 10.3% reported having sex in exchange for protection. Transactional sex coupled with the lack of adult support and the fact that a significant proportion of YHH reported their first sexual experience before the age 15 may also suggest possible exploitation and abuse.
This study has identified several factors related to sexual experience among YHH in Rwanda. Some of these are characteristics of youth themselves, while others are linked to the environment in which they are embedded. Having moved more than two times, marijuana use, and the perception of HIV risk infection were significantly associated with having ever had sex. In contrast, being in school and having a close friend were protective for sexual onset.
These findings are consistent with prior literature in indicating that sexual behaviors of youth are influenced by various factors. Research has highlighted the role of protective factors in explaining sexual behaviors among youth exposed to a high risk social environment [39
]. For example, being well integrated within the community has beneficial effects across a range of health and social outcomes [34
]. Respondents who had moved often and who did not have a close friend were thus unlikely to feel socially connected to the community. In addition, other studies in Rwanda have shown that YHH face stigma and marginalization [29
] which could have a major impact on their behavior. The results of our study suggest that YHH may use sex as a means of gaining support and establishing themselves in the community. Belonging to community groups was also found to be protective, though the association was not significant.
Among the demographic factors, older age was, not surprisingly, associated with a higher likelihood of having had sex. In contrast, although male gender and years served as head of household were significantly associated to sexual onset at the bivariate level, the relationship does not persist in the final model. As in prior research, the findings showed that being out of school was associated with an elevated likelihood of being sexually experienced [29
One noteworthy finding is with regards to the relationship between HIV/AIDS knowledge and behavior. Although the overall "ABC" knowledge in the sample was very low, a strong association was noticed at the bivariate level between condom use knowledge as a prevention measure and ever had sex. This finding is important as most youth programs providing information about HIV/AIDS focus essentially on abstinence-only education and not condom use. Despite the taboo surrounding the notion of sex, and because adolescents do not always see themselves at risk of HIV infection in spite of their high risk behavior, HIV prevention programs should go beyond abstinence and provide information and skills that will allow youth to make adequate choices, especially with regards to condom use [23
The study findings concerning the perception of HIV risk infection by youth are also worthy of note. Only 31% of youth respondents perceived themselves at risk of HIV infection and they were more likely to have sexual intercourse. This low risk perception coupled with the incomplete HIV/AIDS prevention knowledge and the low level of condom use strongly suggest that HIV prevention campaigns throughout the country have failed in reaching and informing YHH about the risks of HIV infection, and indicate that these efforts should be reinforced. The low numbers of condom use in this sample of YHH did not allow for further analysis.
With regard to non-sexual behaviors and sexual initiation, the findings are consistent with prior research in SSA that shows a high likelihood of engaging in sex among drug users [43
]. On the other hand, alcohol is often recognized as a prompt among youth toward adopting poor sexual behavior was not associated with the outcomes of interest [8
]. Alcohol was found in over 50% of the respondents but it was consumed in moderation, mostly once a week. Similarly, despite the high level of depression observed in this population of YHH [25
], psychosocial distress were not associated with early onset of sexual activity as reported by other studies in SSA [26
Limitations of the study include the fact that the study methodology was cross-sectional for which the direction of causal relationships cannot be determined. In addition, measures of behavior such as sexual activity, number of partners, and age of sexual debut were based on self-report taken at the time of recruitment. Data are thus subject to reporting errors/bias and it is also possible that the use of face-to-face interviews to collect data may have further contributed to reporting errors. Because sexual behaviors are still taboo in Rwanda and may be a source of stigmatization, frequencies of behaviors identified in this study may therefore underestimate actual rates. Finally, this study was limited by sampling orphan YHH from a very remote area in Rwanda, recognized as the poorest in the country. Caution should therefore be exercised when generalizing the study findings to other demographic groups and geographic areas. More research is therefore needed to compare sexual risk behavior among orphans and non-orphans youth in urban or rural areas. A longitudinal study to examine the impact of parental illness or death on sexual behavior is also necessary to determine the effect and causal relationships between variables.