HIV/AIDS - Research and Palliative Care
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The association between adolescent entry into
the trucking industry and risk of HIV among
long-distance truck drivers in India
Ram Manohar Mishra 1
Madhulika Dube 2
Niranjan Saggurti 1
Arvind Pandey 3
Bidhubhusan Mahapatra 1
Sowmya Ramesh 1
1
Population Council, New Delhi,
Department of Statistics, Maharshi
Dayanand University, Rohtak,
Haryana, 3National Institute of
Medical Statistics, Indian Council of
Medical Research, New Delhi, India
2
Abstract: This study examines the relationship between entry into the trucking industry during
adolescence and both sexually transmitted infections (STIs) and infection by the human immunodeficiency virus (HIV) among long-distance truck drivers in India. Data were sourced from
a cross-sectional survey (sample size: 2066) undertaken in 2007 among long-distance truck
drivers. The survey spread across major transshipment locations covering the bulk of India’s
transport volume along four routes. Participants were interviewed about sexual behaviors and
were tested for HIV and STIs. The present authors constructed two synthetic cohorts based on
the participants’ duration of employment in the trucking industry: (1) low (duration #6 years)
and (2) high experience (duration $ 7 years). Based on age at entry into the trucking industry,
participants were termed as either adolescent (age at entry ,18 complete years) or adult entrants
(age at entry $ 18 complete years). In the low-experience cohort, the adolescent entrants were
more likely than the adult entrants to have sex with paid female partners (42.6% versus 27.2%,
respectively; adjusted odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.3–2.9) and to practice inconsistent condom use with such partners (69.1% versus 26.8%, respectively; adjusted
OR: 5.3; 95% CI: 2.4–11.6). However, no significant differences were found in STI and HIV
prevalence between the adolescent and the adult entrants in this cohort. In the high-experience
cohort, the adolescent entrants were about two times more likely than the adult entrants to
practice inconsistent condom use with paid female partners (38.5% versus 26.7%, respectively;
adjusted OR: 1.7; 95% CI: 1.1–2.8) and to test positive for HIV (7.4% versus 4.0%, respectively;
adjusted OR: 1.9; 95% CI: 1.2–3.1) and syphilis (5.7% versus 3.5%, respectively; adjusted OR:
1.8; 95% CI: 1.1–3.1). These results suggest the need for focused behavioral change programs
in HIV prevention interventions for adolescent truckers in India and elsewhere.
Keywords: sexually transmitted infections, condom use, risky sexual behavior, truckers
Introduction
Correspondence: Ram Manohar Mishra
HIV and AIDS Program, Population
Council, Zone 5A, Ground Floor, India
Habitat Centre, Lodi Road, New Delhi
110 003, India
Tel +91 11 2465 1314
Fax +91 11 2464 5060
Email rammanohar7@yahoo.co.in
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http://dx.doi.org/10.2147/HIV.S35003
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It is well documented that long-distance truck drivers and their helpers (collectively
referred to as truckers) play an important role in the spread of sexually transmitted
infections (STIs) and the human immunodeficiency virus (HIV) in many parts of the
world, including India.1–10 Recent evidence suggests that about one-quarter of the
long-distance truck drivers in India have sex with female sex workers (FSWs),7,11,12
constituting about 15%–20% of clients of FSWs,8 and a substantial proportion have
sexual relationships with casual unpaid female partners.7,11 Studies conducted during 2007-2010 have shown that the rate of consistent condom use among truckers in
India was low, at 58%–74% with FSWs and 18%–37% with casual unpaid female sex
partners.7,11,12 Several studies across the country have confirmed high HIV (2%–16%)
and STI (3%–13%) prevalence among long-distance truckers.9,12
HIV/AIDS - Research and Palliative Care 2012:4 141–148
141
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Mishra et al
Truckers constitute a heterogeneous population. Studies
conducted in India indicate that current age, marital status,
literacy, duration of employment in the trucking industry, duration of time spent away from home, alcohol consumption, and
the specific routes on which the truckers usually travel correlate
with different levels of risky sexual behavior and the corresponding prevalence of STIs and HIV among truckers.9,11,12
However, an issue that has received less focus so far is the
possible effect of the age at which truckers enter the trucking
industry on their sexual behavior and STI/HIV status.
Although little is known about the sexual behavior of
adolescent truckers in India, it has been observed that most
of the long-distance truck drivers start working as helpers,
with a substantial number entering the industry in their
adolescence,13 and some adolescent helpers in the past have
reported visiting FSWs.14 Considering that adolescents
have a tendency to take greater risks than adults15–17 and
that behaviors established during adolescence may continue
into later adolescence and early adulthood,15,18,19 it may be
argued that truck drivers who enter the trucking industry in
adolescence may have higher vulnerability toward STIs and
HIV infection than those who enter the industry as adults.
Therefore, in this paper, the authors examine the effect of
adolescent entry into the trucking industry on sexual behavior
and STI/HIV status among long-distance truck drivers in
India. Since longer duration of employment in the trucking
industry correlates with a higher risk among truck drivers
for contracting STIs and HIV,9,11 this study also examines
the effects of adolescent entry into the trucking industry on
sexual behavior and STI/HIV status by duration of employment in the trucking industry.
Methods
Study settings and sampling
The authors used data from a cross-sectional behavioral and
biological survey conducted in 2007 among long-distance
truck drivers in India. Long-distance truck drivers were
defined as truck drivers traveling to destinations over 800 km
from their point of origin. The survey was undertaken at
seven transshipment locations covering the bulk of India’s
transport volume along four routes: North-East, North-South,
North-West, and South-East. Transshipment locations are
places where transporters and brokers operate by linking
truckers with individuals wanting to have goods transported;
route categories are road corridors traveled by long-distance
truck drivers.
A two-stage time-location cluster sampling approach
was used to select respondents for the survey, covering
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2066 long-distance truck drivers, a participation rate of
97%. Participation followed written informed consent, and
all data were recorded in an anonymously linked manner
using numerically coded cards. Behavioral data, including
information about demographics, work, sexual partners, and
condom use, were collected through face-to-face interviews,
using a pretested, precoded questionnaire translated into
local languages. Blood and urine samples were collected
from all participating truckers. A blood sample (5 mL),
obtained by antecubital venipuncture, was collected in a
vacutainer, clotted for separation of serum, and stored at
2°C–8°C. A 30 mL urine sample was collected, from which
2 mL was stored in a urine specimen transport tube as per
the protocol of the Aptima Combo 2® Assay (Gen-Probe
Incorporated, San Diego, CA). Sera were tested for both
HIV-1 and HIV-2 using the Microlisa HIV® kit (J Mitra &
Co, Pvt Ltd, New Delhi, India) and the Genedia® HIV 1/2
ELISA 3.0 Kit (Green Cross Medical Science Corp, Chungbuk,
Korea). Serologic tests for syphilis were performed using
the Rapid Plasma Reagin Test Kit (Span Diagnostics
Limited, Surat, India) and reactive serology was confirmed
by Treponema pallidum hemagglutination assay (TPHA)
(Syphagen TPHA Kit; Biokit, SA, Lliça d’Amunt, Spain).
All cases with reactive rapid plasma reagin serology and
TPHA positivity were considered positive for syphilis. To
diagnose Neisseria gonorrhoeae and Chlamydia trachomatis
infections, urine samples were tested using the TranscriptionMediated Amplification Assay and the Dual Kinetic Assay
(Gen-Probe Incorporated).
Ethical considerations
All relevant institutional review boards (Health Ministry
Screening Committee, Government of India; Scientific
Advisory Committee, National AIDS Research Institute;
Protection of Human Subjects Committee, Family Health
International; and Scientific Advisory Committee and
Ethical Committee, National Institute of Medical Statistics)
approved the study. As stated, participation followed written informed consent, and all data were recorded in an
anonymously linked manner using numerically coded cards.
Participants were given information on safe sex practices and
HIV prevention and care facilities in the area. Numerically
coded cards were provided to the participants for receiving
test results and free treatment for syphilis at clinics being
run under the Kavach HIV prevention program for truckers
at major transshipment locations around India. More information about the survey methodology and salient findings
can be found elsewhere.10,20,21
HIV/AIDS - Research and Palliative Care 2012:4
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Sociodemographic and work-related characteristics
The sociodemographic and work-related characteristics of
respondents included age (in completed years), literacy
(defined as ability to read and write [yes/no]), marital status
(currently married/not currently married), ownership of truck
by respondent (yes/no), and route category (North-East,
North-South, North-West, South-East).
Adolescent and adult entrants
The key independent variable in this study was the age at
which respondents entered the trucking industry. Drivers
who entered the industry before 18 complete years of age
were termed adolescent entrants, while those who entered
the industry at 18 complete years of age or older were termed
adult entrants. The cutoff age of 18 years was chosen because
it is the legal age of adulthood in India, when people are
expected to be mature enough to be given important rights
such as the right to vote22 or the right to consume tobacco
products.23,24
Duration of employment in the trucking industry
Two synthetic cohorts (termed low-experience and highexperience cohorts) were constructed based on the respondents’ duration of employment in the trucking industry.
The low-experience cohort comprised respondents who
had worked as truckers for 6 years or less, while the highexperience cohort comprised those who had worked as
truckers for 7 years or more. The cutoff point was selected to
be 6 years because the difference in the average age at entry
into the trucking industry for adolescent and adult entrants, as
shown in the preliminary analysis of the data (see “Statistical
analyses” section), was about 6 years.
Sexual behavior
Multiple indicators were used to measure the sexual behavior
of respondents. These included age at first sexual intercourse;
sexual partnerships with paid female partners, nonpaid
female partners, and male or transgender partners; and
inconsistent condom use with these partners. “Paid female
partner” was defined as a woman to whom the respondent
paid cash in exchange for sex. “Nonpaid female partner” was
defined as a woman to whom the respondent was not married
and to whom the respondent did not pay cash in exchange
for sex. “Inconsistent condom use” was defined as failure
to use a condom in every sexual encounter with a particular
type of sexual partner for a minimum of the past 12 months.
To assess inconsistent condom use, participants were asked,
HIV/AIDS - Research and Palliative Care 2012:4
Effect of age at entry into the trucking industry on HIV
for each type of sexual partner, whether they used a condom
in each sexual act and the time elapsed since they had been
using condoms in every sexual act with the particular type of
sexual partner. Using these questions, dummy variables for
inconsistent condom use with the different types of sexual
partners were computed.
Prevalence of STIs and HIV infection
A respondent was considered to have an STI if at least one
of the following three STIs, for which prevalence was given,
was found to be present: syphilis, N. gonorrhoeae, and
C. trachomatis. A respondent was termed HIV positive if
he tested positive for HIV-1, HIV-2, or both.
Statistical analyses
Appropriate sampling weights were used to account for
differential probabilities of selection and for differential
nonresponse rates across survey locations. Use of sampling
weights provided unbiased estimates of the proportions,
averages, and regression coefficients. Details regarding
calculation of sampling weights are described elsewhere.20
Cross-tabulations were used to examine the differences in
background characteristics, sexual behavior, and STI and HIV
prevalence between the adolescent and the adult entrants and
between the low-experience and the high-experience cohorts.
The chi-square test and the unpaired t-test were applied to
test the significance of the differences in sociodemographic
characteristics. To assess the effects of age at entry into and
duration of employment in the trucking industry on sexual
behavior and STI/HIV prevalence among truck drivers,
separate multivariate logistic regression models were estimated with the following binary (yes/no) outcome variables:
(1) whether had first sexual intercourse before the age of
18 years; (2) whether had sex with paid female partners in the
past 12 months; (3) whether practiced inconsistent condom use
with paid female partners in the past 12 months; (4) whether
had sex with nonpaid female partners in the past 12 months;
(5) whether practiced inconsistent condom use with nonpaid
female partners in the past 12 months; (6) whether had sex
with male or transgender partners in the past 12 months;
(7) whether tested positive for HIV; (8) whether tested positive for syphilis; and (9) whether tested positive for any STI.
All sociodemographic and work-related characteristics except
for current age were controlled in the multivariate analyses to
estimate adjusted odds ratios (ORs) and their 95% confidence
intervals (CIs). The current age of the respondents was not
included in the model so as to avoid problems of collinearity, as current age was determined by variables measuring
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age at entry into and duration of employment in the trucking
industry. Analyses were repeated and stratified by duration
of employment in the trucking industry, because of its strong
association with STI and HIV status among truck drivers.
The statistical software Stata (v 11.1; StataCorp LP, College
Station, TX) was used for analyses.
Results
Of the 2066 respondents covered in the survey, 555 (26.9%)
were adolescent entrants and 1511 (73.1%) were adult
entrants. A total of 705 (34.1%) participants belonged to
the low-experience cohort, and 1361 (65.9%) belonged
to the high-experience cohort. The low-experience and
high-experience cohorts had 113 (16.0%) and 442 (32.5%)
adolescent entrants, respectively (Table 1). Compared with
adult entrants, a significantly lower proportion of adolescent
entrants were currently married (75.7% versus 68.5%,
respectively; P = 0.01) and owned a truck (16.9% versus
7.1%, respectively; P = 0.01). Compared with participants
from the low-experience cohort, a significantly higher
proportion of participants from the high-experience cohort
were currently married (56.3% versus 82.9%, respectively;
P , 0.01). Compared with participants from the highexperience cohort, a higher proportion of participants
from the low-experience cohort were able to both read
and write (84.7% versus 90.1%, respectively; P = 0.01)
and owned a truck (12.5% versus 17.6%, respectively;
P = 0.02).
Table 2 shows that adolescent entrants were about four
times more likely than adult entrants to have experienced
their first sexual intercourse before the age of 18 years
(54.5% versus 25.5%, respectively; adjusted OR: 3.6;
95% CI: 2.9–4.4), about two times more likely than adult
entrants to have practiced inconsistent condom use with
paid female partners in the past 12 months (46.4% versus
26.8%, respectively; adjusted OR: 2.2; 95% CI: 1.5–3.2),
about three times more likely than adult entrants to have
had sex with male or transgender partners in the past
12 months (5.3% versus 1.9%, respectively; adjusted OR:
2.7; 95% CI: 1.6–4.7), and about two times more likely
than adult entrants to test positive for HIV (6.0% versus
2.6%, respectively; adjusted OR: 2.4; 95% CI: 1.5–3.9)
and syphilis (4.6% versus 2.7%, respectively; adjusted
OR: 1.8; 95% CI: 1.1–3.0). Differences in sexual behaviors
of participants between the low-experience and the highexperience cohorts in the past 12 months could not reach
statistical significance. However, participants belonging
to the high-experience cohort were more likely than those
from the low-experience cohort to test positive for HIV
(5.1% versus 0.4%, respectively; adjusted OR: 17.3; 95%
CI: 5.1–58.4) and syphilis (4.2% versus 1.2%, respectively;
adjusted OR: 3.5; 95% CI: 1.6–7.4).
Table 1 Sociodemographic and work-related characteristics of long-distance truck drivers by age at entry into and duration of
employment in the trucking industry (India, 2007)
Sociodemographic and
work-related characteristics
Age at entry into trucking industry
a
Duration of employment in trucking industry
b
Adolescent entrants
(n = 555)
Adult entrants
(n = 1511)
P-value
Low experiencec
(n = 705)
High experienced
(n = 1361)
P-value
Mean current age [years (SD)]
Literacye (%)
Currently married (%)
29.0 (7.7)
83.7
68.5
31.8 (7.8)
87.6
75.7
,0.01
0.03
0.01
25.4 (4.9)
90.1
56.3
33.9 (7.5)
84.7
82.9
,0.01
0.01
Mean age at entry into trucking
industry [years (SD)]
Mean duration of employment
in trucking industry [years (SD)]
Ownership of truck (%)
Route categoryf (%)
North-East
15.8 (1.4)
21.6 (4.0)
,0.01
21.2 (5.0)
19.5 (3.8)
,0.01
12.8 (7.2)
9.9 (6.6)
,0.01
4.2 (1.5)
14.2 (6.1)
,0.01
7.1
16.9
0.01
17.6
12.5
0.02
30.9
24.3
0.03
20.6
28.9
,0.01
North-South
North-West
South-East
Age at entry into trucking industry
Adolescent entrants
Adult entrants
25.2
37.2
6.6
25.9
45.1
4.7
24.7
52.8
1.95
26.3
37.9
6.85
–
–
–
–
16.0
84.0
32.5
67.5
,0.01
,0.01
Notes: a“Adolescent entrants” defined as age at entry into trucking industry ,18 complete years; b“adult entrants” defined as age at entry into trucking industry $ 18 complete
years; c“low experience” defined as duration of employment in trucking industry #6 years; d“high experience” defined as duration of employment in trucking industry $ 7 years;
e
“literacy” refers to the ability to both read and write; f“route category” refers to the road corridors on which the respondent usually travels; significance of difference in
percentages across categories was tested using the chi-square test; significance of difference in average values was tested using the unpaired t-test.
Abbreviation: SD, standard deviation.
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Effect of age at entry into the trucking industry on HIV
Table 2 Sexual behavior and prevalence of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection
among long-distance truck drivers by age at entry into and duration of employment in the trucking industry (India, 2007)
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Sexual behavior and
STI/HIV prevalence
Age at first sexual
intercourse ,18 years
Paid female partners
(past 12 months)
Had sex with
Inconsistent condom
use with
Nonpaid female partners
(past 12 months)
Had sex with
Inconsistent condom
use with
Male or transgender
partners (past 12 months)
Had sex with
Inconsistent condom
use with
STI/HIV prevalence
HIV
Syphilis
Neisseria gonorrhoeae
Chlamydia trachomatis
Any STIg
Age at entry into trucking industry
a
Duration of employment in trucking industry
b
c
Adolescent entrants
[% (N)]
Adult entrants
[% (N)]
Adjusted OR
(95% CI)
Low experienced
[% (N)]
High experiencee
[% (N)]
Adjusted ORc
(95% CI)
54.5 (555)
25.5 (1511)
3.6 (2.9–4.4)
27.2 (705)
36.5 (1361)
1.5 (1.2–1.9)
33.8 (555)
46.4 (188)
27.1 (1511)
26.8 (408)
1.3 (1.1–1.6)
2.2 (1.5–3.2)
29.7 (705)
36.5 (209)
28.4 (1361)
30.9 (387)
1.2 (1.0–1.5)
0.7 (0.5–1.1)
21.3 (555)
81.8 (118)
20.0 (1511)
79.7 (302)
1.0 (0.8–1.3)
0.7 (0.4–1.2)
27.9 (705)
80.0 (195)
16.5 (1361)
80.5 (225)
0.8 (0.6–1.1)
1.0 (0.6–2.1)
5.3 (555)
87.2 (29)
1.9 (1511)
65.6 (29)
2.7 (1.6–4.7)
NE
4.4 (705)
75.6 (31)
2.0 (1361)
77.6 (27)
0.9 (0.5–1.5)
NE
6.0 (555)
4.6 (555)
0.7 (555)
0.9 (555)
6.1 (555)
2.6 (1511)
2.7 (1511)
0.1 (1511)
0.1 (1511)
2.8 (1511)
2.4 (1.5–3.9)
1.8 (1.1–3.0)
NE
NE
2.3 (1.4–3.7)
0.4 (705)
1.2 (705)
0.0 (705)
0.1 (705)
1.3 (705)
5.1 (1361)
4.2 (1361)
0.4 (1361)
0.4 (1361)
4.9 (1361)
17.3 (5.1–58.4)
3.5 (1.6–7.4)
NE
NE
3.7 (1.8–7.5)
Notes: a“Adolescent entrants” defined as age at entry into the trucking industry ,18 complete years; b“adult entrants” defined as age at entry into the trucking industry
$ 18 complete years; cORs were adjusted for literacy (yes/no), marital status (currently married/not currently married), ownership of truck by respondent (yes/no), and route
categories (North-East, North-South, North-West, South-East) by using multivariate logistic regression analyses; adult entrants were considered as reference category to
examine the effects of age at entry into the trucking industry on outcomes. Low experience cohort was considered as reference category to examine the effect of duration
of employment in the trucking industry on outcomes. d“low experience” defined as duration of employment in the trucking industry #6 years; e“high experience” defined as
duration of employment in the trucking industry $ 7 years; multivariate logistic regression models were not estimated because of small cell frequencies; g“any STI” defined as
presence of at least one of the three STIs syphilis, N. gonorrhoeae, and C. trachomatis.
Abbreviations: CI, confidence interval; NE, not estimable; OR, odds ratio.
Table 3 shows results from the duration-stratified analyses.
Adolescent entrants were significantly more likely than adult
entrants to have experienced their first sexual intercourse
before the age of 18 years, both in the low-experience
(46.3% versus 23.6%, respectively; adjusted OR: 2.8; 95%
CI: 1.8–4.3) and the high-experience cohort (56.6% versus
26.8%, respectively; adjusted OR: 3.8; 95% CI: 3.0–4.9). In
the low-experience cohort, the adolescent entrants were about
twice as likely as the adult entrants to have had sex with paid
female partners in the past 12 months (42.6% versus 27.2%,
respectively; adjusted OR: 1.9; 95% CI: 1.3–2.9), about five
times more likely than the adult entrants to practice inconsistent condom use in such relationships (69.1% versus 26.8%,
respectively; adjusted OR: 5.3; 95% CI: 2.4–11.6), and about
four times more likely than the adult entrants to have sex with
male or transgender partners (17.7% versus 1.9%, respectively;
adjusted OR: 3.8; 95% CI: 1.7–11.2). However, no significant
differences were found in STI and HIV prevalence between
the adolescent and the adult entrants in this cohort. In the
HIV/AIDS - Research and Palliative Care 2012:4
high-experience cohort, the adolescent entrants were about
two times more likely than the adult entrants to practice
inconsistent condom use with paid female partners (38.5%
versus 26.7%, respectively; adjusted OR: 1.7; 95% CI: 1.1–2.8)
and to test positive for HIV (7.4% versus 4.0%, respectively;
adjusted OR: 1.9; 95% CI: 1.2–3.1) and syphilis (5.7% versus
3.5%, respectively; adjusted OR: 1.8; 95% CI: 1.1–3.1).
Discussion
This study shows that long-distance truck drivers in India who
enter the trucking industry during their adolescence are at significantly higher risk of contracting STIs and HIV than those
who enter the industry as adults. The duration of employment
in the trucking industry also exhibits significant association
with higher STI and HIV prevalence, especially among the
adolescent entrants. Adolescent entrants were more likely to
experience sexual debut at an early age, exhibit high-risk sexual
behavior, and exhibit higher STI and HIV prevalence than adult
entrants. The differential in sexual behavior between the ado-
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Mishra et al
Table 3 Effect of age at entry into the trucking industry on sexual behavior and prevalence of sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV) infection among long-distance truck drivers stratified by duration of employment in the trucking
industry (India, 2007)
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Sexual behavior and
STI/HIV prevalence
Age at first sexual
intercourse ,18 years
Paid female partners
(past 12 months)
Had sex with
Inconsistent condom
use with
Nonpaid female partners
(past 12 months)
Had sex with
Inconsistent condom
use with
Male or transgender
partners (past 12 months)
Had sex with
Inconsistent condom
use with
STI/HIV prevalence
HIV
Syphilis
Neisseria gonorrhoeae
Chlamydia trachomatis
Any STIg
High experience
a
b
c
Adolescent entrants
[% (N)]
Adult entrants
[% (N)]
Adjusted OR
(95% CI)
Adolescent entrantsd
[% (N)]
Adult entrantse Adjusted ORc
[% (N)]
(95% CI)
46.3 (113)
23.6 (592)
2.8 (1.8–4.3)
56.6 (442)
26.8 (919)
3.8 (3.0–4.9)
42.6 (113)
69.1 (48)
27.2 (592)
26.8 (161)
1.9 (1.3–2.9)
5.3 (2.4–11.6)
31.5 (442)
38.5 (139)
26.9 (919)
26.7 (247)
1.1 (0.8–1.4)
1.7 (1.1–2.8)
30.8 (113)
87.6 (35)
27.3 (592)
78.4 (162)
0.7 (0.3–1.5)
1.3 (0.2–8.1)
18.9 (442)
79.4 (84)
15.3 (919)
81.2 (141)
1.0 (0.6–1.7)
1.1 (0.5–3.9)
17.7 (113)
94.2 (20)
1.9 (592)
41.6 (11)
3.8 (1.7–11.2)
NE
2.1 (442)
71.8 (9)
2.0 (919)
80.5 (18)
1.1 (0.5–3.1)
NE
0.7f
0.4f
0.0f
0.7f
1.1 (113)
0.3f
1.3f
0.0f
0.0f
1.3 (592)
NE
NE
NE
NE
1.3 (0.3–19.7)
7.4f
5.7f
0.9f
0.9f
7.4 (442)
4.0f
3.5f
0.2f
0.1f
3.8 (919)
1.9 (1.2–3.1)
1.8 (1.1–3.1)
NE
NE
2.1 (1.3–3.6)
Notes: a“Adolescent entrants” defined as age at entry into the trucking industry ,18 complete years; b“adult entrants” defined as age at entry into the trucking industry
$ 18 complete years; cORs were adjusted for literacy (yes/no), marital status (currently married/not currently married), ownership of truck by respondent (yes/no), and route
categories (North-East, North-South, North-West, South-East) by using multivariate logistic regression analyses; adults entrants were considered as reference category; d“low
experience” defined as duration of employment in the trucking industry #6 years; e“high experience” defined as duration of employment in the trucking industry $ 7 years;
multivariate logistic regression models were not estimated because of small cell frequencies; ftotal in group not shown; g“any STI” defined as presence of at least one of the three
STIs syphilis, N. gonorrhoeae, and C. trachomatis.
Abbreviations: CI, confidence interval; NE, not estimable; OR, odds ratio.
lescent and the adult entrants was particularly substantial in the
low-experience cohort, whereas the differential in STI and HIV
prevalence between the adolescent and the adult entrants could
reach statistical significance in the high-experience cohort.
These findings are consistent with results from research
in various other settings that determined early initiation of
sexual intercourse was linked with HIV high-risk behavior25–29
and was associated with longer periods of risk taking in later
adolescence and early adulthood.15–19 This evidence suggests
that sexual debut at an early age may be one of the critical
factors behind the differential in high-risk sexual behavior
between adolescent and adult entrants in the low-experience
cohort. The higher vulnerability of adolescent entrants compared with that of adult entrants may also be explained, at
least partly, by the following two factors: first, adolescent boys
who are believed to be “risk takers” – owing to a combination
of physiological sexual urge, peer influences, and a need for
experimentation16,17 – are more likely to engage in riskier
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Low experience
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behaviors, including commercial sex and sexual relationships
with male or transgender partners, if exposed to the environmental factors associated with the trucking industry, such as
high mobility, easy access to FSWs, and interaction with men
who are often away from their families (eg, senior drivers,
other helpers, males working at roadside eating establishments, transgender people, and so forth); second, some of the
senior drivers force adolescent helpers into “survival sex.” The
ability of helpers to resist and negotiate with the senior drivers
is often limited, because in most cases they are appointed on
contract by the drivers themselves.30 Although this study did
not collect specific information about coerced sexual activities
between drivers and helpers, this could be an important area
for future research and intervention.
The low STI and HIV prevalence observed in the
low-experience cohort could be explained, at least to some
extent, by several factors such as the overall declining trend
in STI and HIV prevalence in India among high-risk groups
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(including truckers, FSWs, and men who have sex with male or
transgender partners),11,31,32 implementation of high-intensity
HIV prevention programs among high-risk groups during
the past decade,32,33 and the low infectivity of HIV through
unprotected sexual contact in the absence of STIs.34
These findings are important because, to the best of the
authors’ knowledge, there has not been any study previously that
has conducted a detailed examination of the effect of entry into
the trucking industry during adolescence on the sexual behavior
of long-distance truck drivers in India. A connection between
age of entry into the trucking industry and sexual behavior of
truckers in India has critical policy implications regarding HIV
prevention programs. HIV prevention programs need to cover
long-distance truckers during their initial years of working,
when the truckers are most likely to initiate the risk-taking
behaviors that in the long run result in the higher prevalence
of STIs and HIV infection among truckers. Hence, concerted
efforts may be required to sensitize and inform adolescent helpers about the risks and consequences of STIs and HIV infection.
One possible intervention could be to convince transporters and
brokers (the middlemen on whom long-distance truck drivers
in India largely depend for their business) to recruit helpers
themselves, rather than leaving recruitment primarily to the
drivers, and sensitize them to this issue. This may provide
some autonomy to helpers in order to avoid sexual relationships
forced on them by senior drivers.
Although this study offers important findings, the results
must be interpreted cautiously, by considering certain study
limitations. The participants in the survey were adults working
as long-distance truck drivers. Therefore, the findings are applicable to truckers who either started working as truck drivers or
were promoted after working as helpers; the findings are not
applicable to individuals who worked as helpers but were never
promoted to truck drivers. Nonetheless, considering the high
vulnerability of adolescent truckers to STIs and HIV, similar
studies are needed among helpers to understand the effects
of adolescent entry into the trucking industry on their sexual
behavior and STI/HIV status. The behavioral measures used
in this study were derived from self-reports, which are vulnerable to recall and social desirability bias. The HIV prevalence
among the low-experience cohort was very low, which limited
the choices for analysis of HIV data in this cohort.
Conclusion
In summary, the current study documents that long-distance truck drivers in India who enter the trucking industry
during their adolescence are more likely than those who
enter the industry as adults to display high-risk behavior
HIV/AIDS - Research and Palliative Care 2012:4
Effect of age at entry into the trucking industry on HIV
and to have higher STI and HIV prevalence. These data
highlight the need for HIV prevention programs to start
focusing on adolescent truckers as early as possible during their initial years of working in order to maximize the
effects of HIV prevention interventions. Losing adolescent
truckers from the coverage of HIV prevention programs
may be a lost opportunity in preventing truckers from
contracting HIV.
Acknowledgments/disclosure
This paper was written as part of a mentorship program within
the Knowledge Network project coordinated by the Population
Council, which is a grantee of the Bill and Melinda Gates
Foundation through Avahan, the foundation’s India AIDS
Initiative. The views expressed herein are those of the authors
and do not necessarily reflect the official policy or position of
the Bill and Melinda Gates Foundation and Avahan.
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