RESEARC H Open Access Are Nepali students at risk of HIV? A cross- sectional study of condom use at first sexual intercourse among college students in Kathmandu Ramesh Adhikari 1,2 Abstract Background: Condoms offer the best protection against unintende d pregnancies and sexually transmitted infections. Little research has been conducted to determine the prevalence and investigate the influencing factors of cond om use at first sexual intercourse among college students. Methods: A self-administered questionnaire was completed by 1137 college students (573 male and 564 female) in the Kathmandu Valley. Analyses were confined to 428 students who reported that they have ever had sexual intercourse. The association between condom use at first sexual intercourse and the explanatory variables was assessed in bivariate analysis using Chi-square tests. The associations were further explored using multivariate logistic analysis in order to identify the significant predictors after controlling for other variables. Results: Among the sexually active students, less than half (48%) had used condoms during first sexual intercourse. The results from the logistic regression analysis revealed that age, caste and/or ethnicity, age at first sexual intercourse, types of first sex partner, alcohol consumption and mass media exposure are significant predictors for condom use at first sexual intercourse among the college students. Students in the older age groups who had first sex were about four times (16 to 19 years old) (OR = 3.5) more likely and nine times (20 or older) (OR = 8.9) more likely than the students who had sex before 16 years of age to use condoms at first sexual intercourse. Moreover, those students who had first sex with commercial sex worker were five times (OR = 4.9) more likely than those who had first sex with their spouse to use condoms at first sex. Furthermore, students who had higher exposure to both print and electronic media were about twice (OR = 1.75) as likely as those who had lower media exposure to use condoms. On the other hand, students who frequently consumed alcohol were 54% (OR = 0.46) less likely to use condoms at first sexual intercourse than those who never or rarely consumed alcohol. Conclusions: The rate of condom use at first sexual intercourse is low among the students. It indicates students are expo sed to health hazards through their sexual behaviour. If low use of condom at first sex continues, vulnerable sexual networks will grow among them that allow quicker spreading of sexually transmitted diseases and HIV. Findings from this study point to areas that policy and programmes can address to provide youth with access to the kinds of information and services they need to achieve healt hy sexual and reproductive lives. Correspondence: rameshipsr@gmail.com 1 Geography and Population Department, Mahendra Ratna Campus, Tribhuvan University, Kathmandu, Nepal Adhikari Journal of the International AIDS Society 2010, 13:7 http://www.jiasociety.org/content/13/1/7 © 2010 Adhikari; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribut ion, and reproduction in any medium, provided the original work is properly cited . Background The Federal Democratic Republic of Nepal is a land- locked country in south Asia. It lies between the two of the mos t populous countries of the world: China in the north and India in the south, east and west. These countries are rank ed as the first and the second largest countries of the world, respectively, in size of popula- tion. T he total population of N epal was 27.5 million in 2009 [1]. About one in five of Nepal’ s people are in the age group of 15 to 24 years [2]. HIV/AIDS has beco me a global problem and has spread all over the world. The latest statistics estimate that approximately 33.4 million people worldwide were living with HIV/AIDS by the end of 2008. Of these, 4.7 million people were in Asia. India, Nepal’ s neighbour, accounts for roughly half of Asia’ s HIV prevalence. With the exception of Thailand, every country in Asia has a n adult HIV prevalence of less than 1%. However, owing to the region’s large population, Asia’scompara- tively low HIV prevalence translates into a substantial portion of the global HIV burden in terms of numbers [3]. Like other countries in Asia, Nepal is susceptible to HIV. The country is indeed facing critical challenges posed by the rapid spread of HIV/AIDS. By October 2009, about 15,000 cases of HIV infection and about 2600 cases of AIDS had been officially reported. Among these HIV cases, more than two in five cases (41%) were in the college/university-going ( 15-29 years) age group [4]. However, given the limitations of Nepal’spublic health surveillance system, the actual number of infec- tions is thought to be much higher. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimat ed that 75,000 people were living with HIV at the end of 2007 [5]. It has been found that one in every 200 young males (0.5%) and one in every 300 females (0.3%) aged 15 to 24 are infected by HIV in Nepal [1]. Studies show that college students engage in a variety of behaviours that put them at risk for serious health problems [6,7]. College students are at risk of sexually transmitted infections, including HIV, due to their pro- pensity to take risks, often with multiple partners, accompanied by an inconsistent use of condoms [8,9]. Ample research has also examined the prevalence of excessive alcohol and other substance use, risky sexual behaviour, and other harmful health behaviours that are not uncommon among college students [10-13]. Similarly, a study found that young adults represent one of the groups at highest risk for HIV infection [14]. A study conducted in colleges in Nepal showed that about two in five male college students (39%) had pre- marital sexual experiences. Among these, more than half reported that they had multiple sex partners. Furthermore, more than one in five (23%) had sexual experience with commercial sex workers, and less than half of them (49%) had used condoms in every act of sexual intercourse with a sex worker [15]. Such risky sexual behaviour increases the risk of contracting an STI or HIV which jeopardizes academic achievement and performance of the students [13,16,17]. Differences in levels of condom use in various popula- tion groups and settings have been identified in the lit- erature. In particular, groups with the lowest levels of education have consistently been the least likely to use condoms, both with non-marital and marital partners [18-22]. Some studies also revealed an in crease in con- dom use in the younger age groups [18,23,24] compared to the older groups. Some studies found that later sexual activity has also been associated with an increased use of condoms [25-27]. Furthermore, alcohol use is highly prevalent among college students, and contributes to rising rates of sexual risk taking [28-31]. Empirical e vi- dence also suggests that the mass media has an impor- tant role in shaping individual reproductive attitudes and behaviours [32-34]. In fact, th e mass media variable is a reliable predictor of condom use among individuals [35,36]. One study showed that men who heard about AIDS through either electronic or print media were 30% to 50% more likely to have used a condom than men not exposed to these media [37]. Many researchers and public health policy makers are particularly interested in the subject of first sexual con- tact. A person’s first sexual intercourse often occurs before the age of 20. This is linked to two factors: t he association between behaviours in the first sexual rela- tionship and the establishment of behavioural patterns throughout life [38-40]; and the recognition that sexual initiation at a very young age is a risk factor for preg- nancies before the age of 20 and acquiring sexually transmitted diseases, including HIV [26,41]. Condom use at first sex is easily remembered. Some studies have found a strong link between first condom use and lifetime use: a 20-fold increase in lifetime use and a 10-fold increase in current use if a condom was used at first sexual contact [42]. There is a limited body of literature that points to condom use at first sexual contact among young people, especially students, and none of the studies has analyzed the data on condom use at first sex in Nepal. It is useful to kn ow about condom u se during first sexual intercourse in Nepal so that priorities and approaches for interventions to prevent risky sexual behaviour can be better designed. This article aims to determine t he prevalence of and investigate the factors associated with condom use at first sexual intercourse among college students in Nepal. Adhikari Journal of the International AIDS Society 2010, 13:7 http://www.jiasociety.org/content/13/1/7 Page 2 of 7 Specifically, it is assumed that students who have sex at a n earlier age, who consume alcohol frequently, who have sex with irregular p artners, and who have lower exposure to mass media use condoms less at first sexual intercourse. The findings o f this study address the gap in knowledge by providing the information on condom use at first sexual intercourse that could assist pro- gramme managers of government agencies and non- governmental organizations and the Government of Nepal in designing appropriate and timely education- based interventions in institutions of secondary and higher education. Methods Data and sampling framework The data used in this paper comes from a cross-sec- tional survey on attitude and behaviour towards premar- ital sex among college students of Kathmandu, the capital of Nepal, carried out in 2006. The survey involved a total of 1137 students (573 male and 564 female) studying in 12 colleges affili ated to Trib huvan University in Kathmandu. An alyses were confined to 428 stude nts who reported that they have ever had sex- ual interco urse. The scientific committe e, which included the Ethical Review Board of the University Grant Commission in Nepal, approved the proposal and provided funding for this study. A two-stage random sampling technique was applied. The first stage included a random selection of 12 col- leges in Kathmandu. In order to select these colleges, a list of all the private and public colleges affiliated with Tribhuvan University and located in the Kathmandu Valley (which includes three districts: Bhaktapur, Lalit- pur and Kathmandu) was obtained from the office of the Vice Chancellor in Kathmandu. This list included colleges that provide intermediate (commonly known as Grades 11 and 12), undergraduate and graduate degrees. In the second stage, two classes were randomly selected from each sampled college. The number of students in a class ranged from 40 to 60. All the colleges are co-edu- cational, and all male and female students present on the day of the interview in the sampled classes were requested to participate in the study. Research instrument and data collection Due to the sensitive nature of the study and the educa- tional background of the respondents, a self-admini- strated, structured questionnaire in the Nepali language was used to obtain information. The questionnaires were first developed in English and then translated into Nepali. Almost all sections pertaining to the behavi oural aspect were based on Behavioral Surveillance Survey questionnaire developed by Family Health International/ Impact [43]. However, necessary modifications were made to suit the sample population. The ques tionnaires were pre-tested among students in a college that had not been selected as part of the study, and later refined as required. The pre-test was conducted to determine whether the questionnaires were in sequential order and the wording in Nepali was understandable or not. Most of the questions were close ended; a few open-ended questions were also included. Female and male students filled in the questionnaire separately in different classrooms. Each student was allocated a separate bench, as in an exam setting, before the questionnaire was distributed to them. A mal e researcher supervised the male students’ class while a female researcher su pervis ed the female students’ class. Students were then requested to place the filled-in ques- tionnaire on a table in the corner of each class. Ethical considerations Before starting the study in a sampled college, approval from the campus administrative authority was obtained. All the participants involved in the study were full y informed about the nature of the study, the research objectives, and the confidentiality of the data. A fter this, verbal consent was obtained from the participants before they were enrolled in the study. The consent form was also written in the local language, stating the study’s objectives, nature of the participant’ sinvolve- ment, risk and benefits, and confi dentia lity of the data. Students were requested to read the consent form care- fully. They were given clear options on voluntary parti- cipation. It was also made clear that they could refuse to answer any of the questions and terminate the inter- view if and when they desired. All of the approached students agreed to participate in the study. Confidentiality of infor mation was ensured by removing personal identifiers from the completed ques- tionnaires. The names of sampled colleges were not made publi c and thus, it is not possi ble for anyone out- side the research team to trace reported incidents of sexual behaviour to respondents. Resp ondents were thus protected from any possible adverse repercussions of participating in the study. Variables The measurable outcome of the study is condom use at first sexual intercourse, a dichotomous variable indicat- ingwhetherornottherespondenthadusedacondom during the first sexual encounter. The independent variables used in the study were: sex of the respondent; age; c aste and/or ethnicity; level of education; age at first sexual intercourse; marital status; types of first sexual partner; permanent place of resi- dence; alcohol consumption; mass media exposure; and living arrangement. All these variables were organized Adhikari Journal of the International AIDS Society 2010, 13:7 http://www.jiasociety.org/content/13/1/7 Page 3 of 7 into two or three categories, based on those used in other literature, as well as on the frequency distribution of the variables. The indicators of exposure to mass media include an exposure to radio, television and newspapers. The majority of the students rent rooms in the Kathmand u Valley so it is ass umed that not all of them have TVs in their rooms. Thus, radio and TV were combined and treated as electronic media, and newspaper as print media. Almost all students were exposed to at least one type of media (either electronic or print). Because of this, the mass media variable was organized into two cat egories. If a student was exposed to only one type of media, it was considered as low exposure; if a student was exposed to both print and electronic media, it was considered as high exposure. Similarly, some ethnic groups in Nepal offer alcohol to the gods in religious ceremonies, and people have to consume alcohol in these ceremonies. Therefore, this variable w as categorized into two: (1) never/rarely con- sume alcohol and (2) frequently consume alcohol (two or three times a week). The variable, “ living arrangement”, is also organized into two categories: those students who live with their family members were considered as “ with biological family"; those who live away from family members were considered as “ without biological family”. The other independent variables were categorized in the same way. Methods of analysis All completed survey questionnaires were entered into a database after manual coding and validation. Data entry and validity checks were performed for all the question- naires by using the computer software programme, dBase IV. The cleaned and validated data w as trans- ferred into the SPSS software programme for further processing and analysis. Both bivariate and multivariate techniques were applied in the analysis. The Chi-square test was used to test the association between the variables. Those vari- ables that were significant in the bivariate analysis were further reexamined in the multivariate analysis (binary logistic regression) i n order to identify the significant predictors after controlling for other variables. Before the multivariate analysis, multicollinearity among vari- ables was assessed, and the least important variable, which was highly correlated to other variables, was removed from the logistic model. Results Characteristics of the respondents Among the students, ab out tw o in five (39%) (47% boys; 28% girls) had sexual intercourse irrespective of their marital status. Among these sexually active students (n = 428), around 27% were aged 15 to 19. Eleven per- cent reported that they had had sex before the age of 16. A large majority of the sexually active students were from outside of t he Kathmandu Valley. More than a third (34%) of the students consumed alcohol frequently (two or three times a week). Almost half of the students resided with their biological families. Almost all students were exposed to at least one type of mass media (either electronic or print). Furthermore, both male and female college students were general ly aware of HIV/AIDS and knew of at least one mode of transmission of HIV/AIDS (data not shown). Socio-demographics correlate with condom use Among the sexually active students, just less than half (48%) had used condoms d uring their first sexual con- tacts. Table 1 shows t he clear association b etween con- dom use at first sexual intercourse and different socio- demographic characteristics. Of those who used con- doms at their first sex, a significantly higher proportio n than their comparison group: were males; were aged 15 to 19; were from the Brahmin and Chhetri communities; had first sex at age 16 or older; were unmarried; had sex with a boyfriend/girlfriend; were from outside the Kath- mandu Valley; had high exposure to the mass media; and lived with their biological families (Table 1). Binary logistic regression analysis was used to measure the strength of the associatio n between various indepen- dent variables and the probabilities of using condoms at first s ex. Only those variables that had significant asso- ciation i n bivariate analysis we re reassessed in the logis- tic model. Before the multivariate analysis, multicollinearity among th e variables was assessed. It was found that the varia bles, “marital status” and “types of first sex p artner”,werehighlycorrelated(r=0.7). Therefore, the variable, “ marital status” ,wasnot included in the logistic model. Analysis from logistic regression showed that age group, caste and/or ethnicity, age at first sexual inter- course, types of first s ex partner, alcohol consumption, and mass media exposure were significant predictors for condom use at first sexual intercourse. Students aged 20 or older were less likely to use condoms (OR = 0.40) than students aged 15 to 19. Similarly, students from castes other than Brahmin and Chhetri were 40% (OR = 0.60) less likely to use condoms during their first sexual intercourses than those from other castes and ethnic groups. Furthermore, students who had sexual intercourse for the first time in the age groups of 16 to 19 and 20 or older were almost four times (OR = 3.5) and nine times (OR = 8.9) more likely, respectively, than students who had first sex before 16 years to use condoms at first sexual intercourse (Table 2). Adhikari Journal of the International AIDS Society 2010, 13:7 http://www.jiasociety.org/content/13/1/7 Page 4 of 7 Those students who had first sex with a commercial sex worker were about five times more likely than those who had first sex with their spouse to use condoms dur- ing first sexual intercourse. An inverse relationship was observed between alcohol consumption and condom use. Those student s who had frequently consumed alco- hol were 54% (OR = 0.46) less likely to use condoms at first sexual intercourse than those who did not consume alcohol. On the other hand, students who had higher exposure to both print and electro nic media were about twice (OR = 1.75) as likely as who had lower media exposure to use condoms during their first sexual inter- courses (Table 2). Discussion This study shows that condom use at first sexual inter- course is low among college students in Kathmandu, Nepal. If condom use at first sex remains low, vulner- able sexual networks will grow among the students, allowing faster spreading of sexually transmitted diseases and HIV. Our study found that condom use at first sex- ual intercourse varied according to different criteria. Age group, caste and/or ethnicity, age at first sexual intercourse, types of first sex partner, alcohol consum p- tion and mass media exposure were significant predic- tors for using condoms at first sexual intercourse. Table 2 Adjusted odds ratio (OR) and 95% confidence interval (CI) for using condoms at first sexual intercourse by selected predictors Selected predictors OR 95% CI Sex of the respondents Female (ref.) 1.00 Male 1.34 0.81-2.21 Age group 15-19 (ref.) 1.00 20 and above 0.40** 0.23-0.71 Caste/ethnicity Brahmin/Chhetri (ref.) 1.00 Other 0.60* 0.39-0.94 Age at first sexual intercourse Up to 15 years (ref.) 1.00 16-19 years 3.53** 1.58-7.90 20 or more years 8.96*** 3.75-21.42 Types of first sex partner Spouse (ref.) 1.00 Boyfriend/Girlfriend 4.52*** 2.48-8.22 Commercial sex worker 4.98*** 2.54-9.74 Permanent place of residence Outside Kathmandu valley (ref.) 1.00 Kathmandu valley 0.64 0.32-1.30 Alcohol consumption* Never/rarely consumed (ref.) 1.00 Frequently consumed 0.46** 0.28-0.75 Mass media exposure Low exposure (ref.) 1.00 High exposure (both print and electronic media) 1.75* 1.08-2.83 2 Log likelihood 504.68 Cox & Snell R Square 0.185 Note: *** = p < 0.001 ** = p < 0.01 * = p < 0.5 Table 1 Condom use at first sexual intercourse by background characteristics (n = 428) Condom use Yes No Percent Number Sex of the respondents* Female 40.3 59.7 100.0 159 Male 52.0 48.0 100.0 269 Age group** 15-19 58.6 41.4 100.0 116 20 and above 43.6 56.4 100.0 312 Caste/ethnicity** Brahmin/Chhetri 53.1 46.9 100.0 243 Other 40.5 59.5 100.0 185 Level of education Intermediate 52.3 47.7 100.0 88 Undergraduate 47.2 52.8 100.0 233 Graduate degree 44.9 55.1 100.0 107 Age at first sexual intercourse** Up to 15 years 23.4 76.6 100.0 47 16-19 years 50.3 49.7 100.0 195 20 or more years 51.1 48.9 100.0 186 Marital status*** Married 34.5 65.5 100.0 165 Unmarried 55.9 44.1 100.0 263 Types of first sex partner*** Spouse 28.9 71.1 100.0 121 Boyfriend/girlfriend 57.2 42.8 100.0 180 Commercial sex worker 52.0 48.0 100.0 127 Permanent place of residence* Outside Kathmandu Valley 49.5 50.5 100.0 378 Kathmandu Valley 34.0 66.0 100.0 50 Alcohol consumption* Never/rarely consumed 52.7 47.3 100.0 283 Frequently consumed 37.9 62.1 100.0 145 Mass media exposure* Low exposure 44.5 55.5 100.0 290 High exposure (both print and electronic media) 54.3 45.7 100.0 138 Living arrangement With biological family 50.9 49.1 100.0 224 Without biological family (friends/ alone) 44.1 55.9 100.0 204 Total 47.7 52.3 100.0 428 Note: *** = p < 0.001 ** = p < 0.01 * = p < 0.5 Adhikari Journal of the International AIDS Society 2010, 13:7 http://www.jiasociety.org/content/13/1/7 Page 5 of 7 The study also found that students aged 15 to 19 were more likely to use condoms duri ng first sexual inter- course compared with students aged 20 or older. Results from this study are consistent with those of many other studies [18,23,24]. The finding of this study was also consistent with that of other literature: that later sexual intercourse has also been associated with increased use of condoms [25-27]. Many oth er studies have found significant dif ferences in condom use according to the type of relationship with sex partners, defined as casual or fixed/steady [44-46]. Our study also supported the finding of other studies that the level of condom use is higher in those who had first sex with casual or non-steady partners than in those who had first sex with spouses or steady partners. Regarding alcohol consumption, results from this study are similar to most other studies: alcohol use contributes to a lower use of condoms and elevated rates of sexual risk [28-31]. Mass media exposure is another important predictor for condom use at first sexual intercourse. Those stu- dents who were exposed to both electronic and print media were more likely to use condoms than those who had low exposure to these media. This finding is similar to that of other studies [35,36]. Diffusion theorists po s- tulate that the mass media effect contraceptive use by stimulating partners to discuss contraceptive use [47]. Through the sharing of information and mutual feed- back, people give meaning to information, understand each other’s views and influence each other [48]. Thus, discussion of contraceptive use leads to the development of a better understanding between partners of their reproductive health goals. There are some limitations to this study. First, because of the cross-sectional design of the study and the nature of the items used in the logistic regression analysis, t he analysis can only provide evidence of statistical associa- tion between those items and condom use at first sex and can not show cause-effect relationships. Second, all measures w ere self-reported. Thus, responses may have been biased by recall errors or intentional misreporting of behaviour. However, the privacy conditions around the study and the use of self-administered question- naires are likely to have minimized purposeful misreporting. Conclusions The rate of condom use at first sexual intercourse is low among the students. It indicates students are exposed to health hazards through their sexual behaviour. If low use of condoms at first sex continues, vulnerable sexual networks will increase among the students, allowing more growth in the spread of sexually transmitted dis- eases and HIV. Our study showed a positive effect of the mass media on condom use at first sex; information about condom use and sexual risk behaviour, including unsafe sex, should be provided through the mass media. Similarly, students who had sex a t a later age were more likely to use condoms at first sex. Therefore, awareness pro- grammes that encourage postponement of sexual debuts could benefit the students. Findings from this study point to areas that policy and programmes can address to provide youth with access to the kinds of information and services they need to achieve healthy s exual and reproductive lives. Acknowledgements The University Grant Commission, Nepal, provided funding for this study. The author wishes to thank the administrators of all the sampled college in the Kathmandu Valley for their support. He also thanks the students for their participation in the study. Author details 1 Geography and Population Department, Mahendra Ratna Campus, Tribhuvan University, Kathmandu, Nepal. 2 Institute for Population and Social Research, Mahidol University, Salaya, Thailand. Authors’ contributions RA conceived the study and its design, undertook the analysis, and wrote the manuscript. Competing interests The author declares that they have no competing interests. Received: 28 October 2009 Accepted: 2 March 2010 Published: 2 March 2010 References 1. Population Reference Bureau: World Population Data Sheet. . Washington DC 2009. 2. Central Bureau of Statistics: Population Monograph of Nepal. . Kathmandu 2003. 3. UNAIDS and World Health Organization: AIDS Epidemic Update. . Geneva 2009. 4. National Centre for AIDS and STD Control: Cumulative HIV and AIDS Situation of Nepal (as of 17 October, 2009). . Kathmandu . 5. UNAIDS: Report on the global AIDS epidemic. . Geneva 2008. 6. Douglas KA, Collins JL, Warren C, Kann L, Gold R, Clayton S: Results from the 1995 National College Health Risk Behavior Survey. Journal of American College Health 1997, 46:55-66. 7. American College Health Association: American College Health Association National College Health Assessment (ACHA-NCHA) Spring 2005 Reference Group Data Report (abridged). Journal of American College Health 2006, 55(1):5-16. 8. Lewis JE, Malow RM, Ireland SJ: HIV/AIDS Risk in heterosexual college students - A review of a decade of literature. J Am Coll Health 1997, 45(4):147-158. 9. Prince A, Bernard AL: Sexual behaviors and safer sex practices of college students on a commuter campus. Journal of American College Health 1998, 47(1):11-21. 10. Centers for Disease Control and Prevention: Youth risk behavior surveillance - United States, 2005: Surveillance Summaries. Morbidity and Mortality Weekly Report 2006, 55(SS5). 11. Keating XD, Guan J, Pinero JC, Bridges DM: A meta-analysis of college students’ physical activity behaviors. Journal of American College Health 2005, 54:116-125. 12. Mohler-Kuo M, Lee JE, Wechsler H: Trends in Marijuana and Other Illicit Drug Use Among College Students: Results from 4 Harvard School of Public Health College Alcohol Study Surveys: 1993-2001. Journal of American College Health 2003, 52:17-24. Adhikari Journal of the International AIDS Society 2010, 13:7 http://www.jiasociety.org/content/13/1/7 Page 6 of 7 13. Prendergast ML: Substance use and abuse among college students: a review of recent literature. Journal of American College Health 1994, 43:99-113. 14. Joint United Nations Programme on HIV/AIDS: Report on the Global HIV/ AIDS Epidemic. . Geneva, Switzerland 2002. 15. Adhikari R, Tamang J: Premarital sexual behavior among male college students of Kathmandu, Nepal. BMC Public Health 2009, 9:241. 16. Trockel MT, Barnes MD, Egget DL: Health-related variables and academic performance among first-year college students: implications for sleep and other behaviors. Journal of American College Health 2000, 49:125-131. 17. Wechsler H, Davenport A, Dowdall G, Moeykens B, Castillo S: Health and Behavioral Consequences of Binge Drinking in College. A National Survey of Students at 140 Campuses. Journal of the American Medical Association 1994, 272:1672-1677. 18. Agha S: Sexual activity and condom use in Lusaka, Zambia. International Family Planning Perspectives 1998, 24(1):32-37. 19. Benefo KD: Are partner and relationship characteristics associated with condom use in Zambian nonmarital relationships? International Family Planning Perspectives 2004, 30(3):118-127. 20. Kapiga SH, Lugalla JL: Male condom use in Tanzania: results from a national survey. East African Medical Journal 2003, 80(4):181-190. 21. Lagarde E, Caraël M, Glynn JR, Kanhonou L, Abega SC, Kahindo M, Musonda R, Auvert B, Buvé A, Study Group on the Heterogeneity of HIV Epidemics in African Cities: Educational level is associated with condom use within non-spousal partnerships in four cities of sub-Saharan Africa. AIDS 2001, 15(11):1399-1408. 22. Meekers D: Patterns of condom use in urban males in Zimbabwe: evidence from 4600 sexual contacts. AIDS Care 2003, 15(3):291-301. 23. Mnyika KS, Klepp K, Kvale G, Ole-Kingori N: Determinants of high-risk sexual behavior and condom use among adults in the Arusha region, Tanzania. International Journal of STD and AIDS 1997, 8(3):176-183. 24. Hawken MP, Melis RD, Ngombo DT, Mandaliya KN, Ng’ang’a LW, Price J, Dallabetta G, Temmerman M: Opportunity for prevention of HIV and sexually transmitted infections in Kenyan youth: results of a population- based survey. Journal of Acquired Immune Deficiency Syndromes 2002, 31(5):529-535. 25. Lugoe WL, Klepp KI, Skutle A: Sexual debut and predictors of condom use among secondary school students in Arusha, Tanzania. AIDS Care 1996, 8(4):443-452. 26. Svare EI, Kjaer SK, Thomsen BL, Bock JE: Determinants for non-use of contraception at first intercourse: a study of 10,841 young Danish women from the general population. Contraception 2002, 66(5):345-50. 27. Narring F, Wydler H, Michaud PA: First sexual intercourse and contraception: a cross-sectional survey on the sexuality of 16-20-year- olds in Switzerland. Schweiz Med Wochenschr 2000, 130(40):1389-98. 28. Cerwonka ER, Isbell TR, Hansen CE: Psychosocial factors as predictors of unsafe sexual practices among young adults. AIDS Education and Prevention 2000, 12:141-153. 29. Hingson RW, Heeren T, Zakocs RC, Kopstein A, Wechsler H: Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24. Journal of Studies on Alcohol 2002, 63:136-144. 30. Perkins HW: Surveying the damage: A review of research on consequences of alcohol misuse in college populations. Journal of Studies on Alcohol 2002, , Supplement Number 14: 91-100. 31. Wechsler H, Lee JE, Kuo M, Lee H: College binge drinking in the 1990s: a continuing problem. Journal of American College Health 2000, 48:199-210. 32. Westoff CF, Bankole A: Mass media and reproductive behavior in Pakistan, India, and Bangladesh, Demographic and Health Surveys Analytic Report, No. 10 Calverton, MD: Macro International 1999. 33. Foreit KG, de Castro MPP, Franco FDE: The impact of mass media advertising on a voluntary sterilization program in Brazil. Family planning operations research: A book of readings New York: Population CouncilForeit JR, Frejka T 1998, 141-156. 34. Sharan M, Valente TW: Spousal communication and family planning adoption: Effects of a radio drama serial in Nepal. International Family Planning Perspectives 2002, 28(1):16-25. 35. Katz I: Explaining the Increase in Condom Use Among South African Young Females. Journal of Health Communication 2006, 11(8):737-753. 36. Prabawanti C, Riono P: The impact of mass media and non mass media exposure on condom use and treatment seeking behaviour among female sex workers and male clients in Indonesia. Proceedings of the XV International AIDS Conference. Jul 11-16 2004; Bangkok.15 . 37. Waithaka M, Bessinger R: Sexual Behavior and Condom Use in the Context of HIV Prevention in Kenya, . Population Services International Kenya 2001http://pdf.usaid.gov/pdf_docs/PNADA257.pdf, Retrieved on December 12, 2009. 38. Hearst N, Chen S: Condom promotion for AIDS prevention in the developing world: is it working? Stud Fam Plann 2004, 35(1):39-47. 39. Shafii T, Stovel K, Davis R, Holmes K: Is condom use habit forming? Condom use at sexual debut and subsequent condom use. Sex Transm Dis 2004, 31(6):366-72. 40. Teixeira AMFB, Knauth DR, Fachel JMG, Leal AF: Adolescentes e uso de preservativos: as escolhas de jovens de três capitais brasileiras na iniciação e na última relação sexual. Cad Saude Publica 2006, 22(7):1385-96. 41. Kaestle CE, Halpern CT, Miller WC, Ford CA: Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J Epidemiol 2005, 161(8):774-80. 42. Miller KS, Levin ML, Whitaker DJ, Xu X: Patterns of condom use among adolescents: The impact of mother-adolescent communication. American Journal of Public Health 1998, 88:1542-1544. 43. FHI and Impact: Behavioral Surveillance Surveys: Guidelines for Repeated Behavioral Surveys in Populations at Risk of HIV: Family Health International. 2000. 44. Calazans G, Araujo TW, Venturi G, França Junior I: Factors associated with condom use among youth. AIDS 2005, 19(Supl 4):S42-50. 45. Holtzman D, Bland S, Lansky A, Mack KA: HIV-related behaviors and perceptions among adults in 25 states: 1997 Behavioral Risk Factors Surveillance System. Am J Public Health 2001, 91(11):1882-8. 46. Jenkins RA, Manopaiboon C, Samuel AP, Jeeyapant S, Carey JW, Kilmarx PH: Condom use among vocational school students in Chiang Raí, Thailand. AIDS Educ Prev 2002, 14(3):228-45. 47. Rogers EM: Effects of an entertainment-education radio soap opera on family planning behavior in Tanzania. Studies in Family Planning 1999, 30(3):193-211. 48. Bandura A: Social Foundations of Thought and Action: A Social Cognitive Theory Englewood Cliffs, NJ, USA: Prentice-Hall 1986. doi:10.1186/1758-2652-13-7 Cite this article as: Adhikari: Are Nepali students at risk of HIV? A cross- sectional study of condom use at first sexual intercourse among college students in Kathmandu. Journal of the International AIDS Society 2010 13 :7. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Adhikari Journal of the International AIDS Society 2010, 13:7 http://www.jiasociety.org/content/13/1/7 Page 7 of 7 . RESEARC H Open Access Are Nepali students at risk of HIV? A cross- sectional study of condom use at first sexual intercourse among college students in Kathmandu Ramesh Adhikari 1,2 Abstract Background:. Drinking in College. A National Survey of Students at 140 Campuses. Journal of the American Medical Association 1994, 272:1672-1677. 18. Agha S: Sexual activity and condom use in Lusaka, Zambia. International Family. lifetime use and a 10-fold increase in current use if a condom was used at first sexual contact [42]. There is a limited body of literature that points to condom use at first sexual contact among young