Drug and Alcohol Dependence 56 (1999) 47 – 53

Drug and alcohol consumption and sexual risk behaviour among

young adults: results from a national survey
Jesús Castilla a,c,*, Gregorio Barrio b, M. José Belza c, Luis de la Fuente a
a
Secretarı́a del Plan Nacional sobre Sida, Ministerio de Sanidad y Consumo, Madrid, Spain
b
Delegación del Gobierno para el Plan Nacional sobre Drogas, Madrid, Spain
c
Centro Nacional de Epidemiologı́a, Instituto de Salud Carlos III, C/ Sinesio Delgado, 6, 28029 Madrid, Spain

Received 25 September 1998; received in revised form 22 January 1999; accepted 22 January 1999

Abstract

To study the association of the consumption of alcohol and other psychoactive drugs with sexual risk behaviour for HIV
infection, data from a representative sample of the Spanish population aged 18 – 39 years were analysed. A national household
survey was carried out in 1996 using a combination of face-to-face interviews and self-administered questionnaires. The survey
included 5253 subjects aged 18–39 years who provided information on alcohol and drug consumption, number of sexual partners
and condom use with the steady partner and with casual partners in the 12 months before the survey. Of those surveyed, 27.4%
had been drunk at least once and 20.5% had consumed drugs. Both behaviours were associated with male sex, younger age, higher
educational level, being single and having had more than one sexual partner. In the logistic regression analysis adjusting for the
sociodemographic variables, the greater frequency of drunkenness and cannabis use were associated with having more than one
sexual partner. Regular condom use was significantly less frequent among cocaine users and more frequent among opiate users,
but was not associated with the use of other drugs. Sexual risk behaviour (i.e. more than one partner and failure to use a condom
regularly) was more frequent among persons who had been drunk or used cannabis or cocaine. Excessive consumption of alcohol,
and cannabis and cocaine use are independently associated with sexual behaviour involving greater risk of HIV infection or
transmission. © 1999 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: HIV transmission; Alcohol; Substance abuse; Sexual behaviour; Condoms; Population survey

1. Introduction may also show a similar association (Temple et al.,

The identification of situations associated with risk
behaviour is of special interest for the prevention of
sexually transmitted HIV. Several studies have found
an increased incidence of HIV infection in heavy
drinkers and users of non-injected drugs (Penkower et
al., 1991) which has been attributed to the association
of such use with higher risk sexual behaviour (Mc-
Cusker et al., 1990; Larrat et al., 1994; Donovan and
McEwan, 1995). Cocaine and crack are the main drugs
that have been associated with a greater risk of sexual
HIV transmission (McCusker et al., 1990; Siegal et al.
1992; Larrat et al., 1994). Excessive amounts of alcohol
* Corresponding author. Tel.: + 34-91-387 78 02; fax: 34-91-387-
78-16.
E-mail address: jcastill@isciii.es (J. Castilla)
1993; Weinstock et al., 1993; Caetano and Hines, 1995),
although not all studies agree on this (Donovan and
McEwan, 1995).
These associations have primarily been shown in
studies carried out in adolescents (Lowry et al., 1994;
Fontenberry et al., 1997), homosexual men (McCusker
et al., 1990; Paul et al., 1994) and selected heterosexual
populations (Weinstock et al., 1993; Larrat et al., 1994),
but few investigations have described the importance of
these behaviours in population-based studies of young
adults (Leigh et al., 1994).
The possible effect of other drugs has been studied
less frequently. However, this information would be of
great interest given the extensive use of some drugs
such as cannabis (European Monitoring Centre for
Drugs and Drug Addiction, 1998), and the possible
implications this might have in HIV prevention.

0376-8716/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 3 7 6 - 8 7 1 6 ( 9 9 ) 0 0 0 0 8 - 3
48 J. Castilla et al. / Drug and Alcohol Dependence 56 (1999) 47–53
Young adults in Spain have the highest HIV preva-
lence in all of Europe (Downs et al., 1997). Spain is also
one of the countries with the highest per capita con-
sumption of alcohol (Produktschap voor Gedistilleerde
Dranken, 1996) and has high rates of drug use (Eu-
ropean Monitoring Centre for Drugs and Drug Addic-
tion, 1998). Thus, the potential effect of this use is of
special interest in the prevention of sexually transmitted
HIV in the Spanish population.
From a nationally representative survey of the gen-
eral population in Spain, we analysed the association of
alcohol and psychoactive drug use with sexual risk
behaviour for HIV and other sexually transmitted
diseases.
2. Methods
A survey of a representative sample of the Spanish
adult population was carried out in February 1996. The
multistage, stratified random sample included 6301 per-
sons between 18 and 39 years of age. In the first stage
a probability sample was selected from the electoral
districts. The households in these districts were selected
by random routes, and the persons within households
were randomly selected to fill age-group quotas. In 20%
of the interviews the persons originally selected had to
be replaced either because they could not be located
after three visits to the home or because they refused to
answer the questionnaire.
The survey included sociodemographic data as well
as information on health status, use of alcohol and
other psychoactive drugs, and sexual behaviour. The
sociodemographic information was collected by per-
sonal interview in the home of the person surveyed.
Some data considered especially sensitive, such as drug
use and sexual behaviour, were collected by an anony-
mous, self-administered questionnaire.
Information on alcohol use was gathered from two
perspectives. First, the persons interviewed were asked
whether they had consumed alcohol and how many
times they had experienced a subjective loss of control
(drunkenness) during the last 12 months. They were
then asked about the frequency and amount of different
alcoholic beverages consumed in the last week, distin-
guishing between weekday and weekend (Friday, Satur-
day and Sunday) use. This information was used to
calculate the average daily amount of alcohol con-
sumed during the weekend and on weekdays, trans-
formed to millilitres of pure alcohol.
With respect to drug use, the following groups of
psychoactive substances were considered separately: (1)
inhalants; (2) cannabis; (3) amphetamines, including
ecstasy and designer drugs; (4) cocaine, including crack;
(5) hallucinogens; (6) opiates; and (7) tranquillisers,
including sleeping pills. Drugs were considered to have
been used if they had been consumed at least once
during the last 12 months.
Questions on sexual behaviour also referred to the 12
months before the interview, and pertained only to
relations with vaginal or anal penetration. Questions
were asked about the total number of partners, and
about condom use with the steady partner and with
casual partners, regardless of the partner’s sex.
Although the number of partners has been used as an
indicator of sexual risk behaviour for HIV transmis-
sion, condom use must also be taken into account.
Consequently, those persons who had had sexual rela-
tions with more than one person in the last 12 months
and had not used condoms in all their contacts were
considered to be in a ‘risk situation’ (Leigh et al., 1993).
We analysed the association of alcohol consumption
and psychoactive drug use with the sexual behaviour
variables (more than one sexual partner, failure to use
condoms regularly with casual partners, failure to use
condoms regularly with regular partner, and to be in a
‘risk situation’). Both substance use and sexual be-
haviour may be strongly associated with certain so-
ciodemographic situations (Castilla et al., 1998) which
could act as confounding variables. Therefore multiple
logistic regression analysis was performed, including
sex, age, educational level and marital status as covari-
ables. The analysis of condom use was also adjusted for
the number of sexual partners in the last 12 months. In
order to explore more thoroughly the relation between
alcohol use and sexual behaviour, two models were
constructed. In the first model, alcohol use was consid-
ered in four categories (no alcohol use, use without
drunkenness, one to eleven episodes of drunkenness per
year, and one or more episodes per month). In the
second model, average daily alcohol use was broken
down into two variables: weekend use and weekday
use.
The first order interaction terms were assessed and
introduced into the model when significant at a level of
0.05. Statistical comparisons at P B 0.05 were consid-
ered significant. The association between variables was
quantified by means of the adjusted odds ratio (OR)
and its 95% confidence interval (CI).
3. Results
Of the 6301 persons 18–39 years of age surveyed,
5253 (83.4%) answered the self-administered question-
naire containing the questions on sexual behaviour and
drug use. There was no significant difference in the
response rate by sex, age group, educational level or
marital status.
Some 64.5% of those who answered had had a single
sexual partner in the last 12 months, 5.1% had had two
partners and 5.0% had had more than two. About
 J. Castilla et al. / Drug and Alcohol Dependence 56 (1999) 47–53 49

75.2% had consumed alcoholic beverages, 27.4% said Table 2

Proportion of the population surveyed who reported drunkenness or
they had experienced one or more episodes of drunken-
psychoactive drug use during the last 12 months, by sociodemo-
ness, and 20.5% had used psychoactive drugs in the last graphic characteristics
12 months. About 5.0% reported experiencing an aver-
age of more than one episode of drunkenness per Drunkenness (%) Drugs (%) No.
month, and 5.3% had used more than one type of drug.
Sex
The substances consumed by the largest number of Men 40.9 22.6 2395
persons surveyed were cannabis (11.8%), followed by Women 16.0 18.7 2858
tranquillisers (9.5%), cocaine (3.5%) and amphetamines Age (years)
(2.8%) (Table 1). 18–19 37.4 25.1 500
Both drunkenness and psychoactive drug use were 20–24 39.4 24.1 1274
significantly associated with male sex, younger age, 25–29 31.3 21.0 1216
30–34 18.7 16.3 1139
higher educational level, being single, and having had
35–39 13.7 18.0 1114
more than one sexual partner during the last 12 months
(Table 2). Tranquillisers, unlike other drugs, were used Educational le6el
No formal education 17.4 17.4 253
more frequently by women, persons older than 35 years Primary 21.2 17.4 751
of age, and those with a lower educational level. Secondary 28.6 21.2 3302
Table 3 presents the results of the multiple logistic University 30.4 21.4 947
regression models analysing the association between Marital status
alcohol and drug use and at-risk sexual behaviour for Never married 38.9 24.4 2629
HIV infection. After adjusting for the sociodemo- Married 13.8 14.2 2367
Cohabiting 40.0 37.8 135
graphic variables, having had more than one sexual
Other 28.7 38.5 122
partner during the last 12 months was significantly
associated with alcohol use, especially with more fre- Number of partners
None 23.9 15.2 1333
quent episodes of drunkenness, and use of cannabis 1 23.9 19.5 3387
derivatives (Table 3). Use of amphetamines came close \1 58.0 40.0 533
to statistical significance (P =0.054). Failure to use Total 27.4 20.5 5253
condoms was significantly more frequent among co-
caine users, but was not associated with drunkenness or
with the use of other substances (Table 3). Only opiate
Table 1
users used condoms significantly more frequently with
Alcohol and psychoactive drug use among persons surveyed
casual partners (P= 0.045).
Number % Since risk of HIV infection can depend on the num-
ber of sexual partners, but only when condoms are not
Alcohol consumed in the last 12 months used, we developed an indicator considering those per-
None 1303 24.8
sons who had had more than one partner in the last 12
Consumption with no episodes of drunkenness 2512 47.8
One to eleven episodes of drunkenness/year 1173 22.3 months, but had not used condoms regularly. This
One or more episodes of drunkenness/month 265 5.0 potentially higher risk behaviour was significantly more
Amount of alcohol consumed on weekend (ml/day) frequent among those persons who had experienced an
0 2447 46.6 episode of drunkenness or had consumed cannabis or
1–59 2408 45.8 cocaine in the last 12 months (Table 3). The odds for
60–99 261 5.0 persons averaging at least one episode of drunkenness
]100 137 2.6
per month were about three times those for people who
Amount of alcohol consumed on weekdays (ml/day) did not drink. It should be pointed out that alcohol use
0 3938 75.0 without drunkenness was not associated with higher
1–59 1184 22.5
]60 131 2.5
risk sexual behaviour.
The measures of association between quantities of
Drugs consumed in the last 12 months
Inhalants 14 0.3
alcohol consumed in the last week and the sexual
Cannabis 618 11.8 behaviour variables, adjusted by sociodemographic
Cocaine/crack 185 3.5 variables and by drug use, are presented in Table 4. The
Amphetamines/ecstasy 146 2.8 situation defined as ‘sexual risk’ was significantly more
Hallucinogens 68 1.3 frequent among users of large amounts of alcohol, both
Opiates 55 1.0
Tranquillisers 499 9.5
on weekdays and during the weekend, however, the
Any drug 1077 20.5 increased risk is produced by a different mechanism in
each case. Having had more than one partner was
 50
Table 3
Association of alcohol and psychoactive drug consumption with sexual behaviour in the last 12 monthsa

More than one sexual partnerb Failure to use condoms regularlyc

J. Castilla et al. / Drug and Alcohol Dependence 56 (1999) 47–53

More than one sexual partner
and no regular condom useb

With casual partners With regular partners

% OR CI 95% % OR CI 95% % OR CI 95% % OR CI 95%

Alcohol
No consumption 4 1 66 1 67 1 2 1
Consumption without drunkenness 35 1.4 1.0–2.0 37 1.2 0.8–1.7 52 1.1 0.9–1.3 21 1.1 0.7–1.8
One to eleven episodes of drunkenness/year 19 2.4 1.7–3.3 42 1.0 0.7–1.6 54 1.0 0.8–1.3 8 1.8 1.2–2.9
One or more episodes of drunkenness/month 7 3.5 2.3–5.3 58 1.2 0.7–2.1 65 1.2 0.8–1.8 3 3.6 2.1–6.2
Psychoacti6e drugs
No use 8 1 56 1 63 1 3 1
Inhalants 43 1.6 0.5–5.7 33 0.8 0.1–5.4 70 1.4 0.3–6.0 21 1.2 0.3–5.0
Cannabis 28 2.0 1.5–2.6 39 1.0 0.7–1.5 57 1.3 1.0–1.7 15 2.0 1.4–2.8
Cocaine/crack 34 1.3 0.8–2.0 44 2.1 1.0–4.2 68 2.0 1.2–3.2 23 2.1 1.3–3.6
Amphetamines/ecstasy 38 1.6 1.0–2.6 33 0.6 0.3–1.3 55 0.9 0.5–1.5 19 1.0 0.6–1.9
Hallucinogens 35 0.8 0.4–1.5 43 2.1 0.8–5.8 57 0.9 0.4–1.7 21 0.9 0.4–1.9
Opiates 35 0.9 0.5–1.8 23 0.3 0.1–1.0 66 1.2 0.6–2.5 18 0.8 0.3–1.7
Tranquillisers 11 1.2 0.8–1.7 56 1.3 0.8–2.1 64 1.0 0.8–1.3 5 1.1 0.7–1.8

a
%, unadjusted percentage; OR, odds ratio, adjusted; CI, confidence interval.
b
Model adjusted by gender, age, educational level and marital status.
c
Model adjusted by gender, age, educational level, marital status and number of sexual partners in the last 12 months.
Table 4

J. Castilla et al. / Drug and Alcohol Dependence 56 (1999) 47–53

Association between amount of alcohol consumed in the last week and sexual behaviour during the last 12 monthsa

More than one sexual partnerb Failure to use condoms regularlyc More than one sexual partner
and no regular condom useb

With casual partners With regular partners

% OR CI 95% % OR CI 95% % OR CI 95% % OR CI 95%

Weekday alcohol consumption (ml/day)

0 8 1 53 1 61 1 4 1
1–59 15 1.2 0.9–1.5 50 1.2 0.8–1.7 68 1.3 1.1–1.6 8 1.2 0.9–1.7
]60 23 1.3 0.7–2.2 65 2.7 1.3–5.7 69 1.5 0.9–2.5 17 2.0 1.1–3.7
Weekend alcohol consumption (ml/day)
0 5 1 62 1 65 1 2 1
1–59 12 1.5 1.2–1.9 47 0.9 0.6–1.2 61 1.0 0.8–1.2 5 1.4 1.0–1.9
60–99 30 2.5 1.7–3.6 46 1.0 0.6–1.8 54 0.8 0.6–1.2 16 2.4 1.5–3.9
]100 33 2.3 1.4–3.8 43 0.7 0.4–1.4 62 1.2 0.7–1.9 18 2.0 1.1–3.8

a
%, unadjusted percentage; OR, odds ratio, adjusted; CI, confidence interval.
b
Model adjusted by gender, age, educational level, marital status and drug use in the last 12 months.
c
Model adjusted by gender, age, educational level, marital status, use of different drugs and number of sexual partners in the last 12 months.

51
52 J. Castilla et al. / Drug and Alcohol Dependence 56 (1999) 47–53
associated with increased alcohol consumption during
the weekend, but not on weekdays. On the other hand,
failure to use condoms was specifically associated with
alcohol use on weekdays, but not on weekends. Among
persons who had used alcohol in the last 12 months,
but did not report any episodes of drunkenness, no
significant association was found between the amount
of alcohol consumed in the last week and higher risk
sexual behaviour.
4. Discussion
This study shows an independent association of both
excessive alcohol use and cannabis or cocaine use with
higher risk sexual behaviour for infection with HIV and
other sexually transmitted diseases among the young
adult population in Spain. However, there are some
specific characteristics of the type of sexual risk situa-
tions that are associated with the consumption of each
of these substances.
Previous studies have described more frequent sexual
risk behaviour among cocaine or crack users in groups
of homosexual men men (McCusker et al., 1990; Paul
et al., 1994), in adolescents (Lowry et al., 1994;
Fontenberry et al., 1997) and in the heterosexual popu-
lation (Larrat et al., 1994). In agreement with some of
these studies, we found that cocaine use is associated
with less condom use both with the regular partner and
with casual partners. None of the other drugs studied
showed a similar association. On the other hand, the
use of cocaine was not independently associated with a
greater number of sexual partners. Persons who re-
ported more frequent drunkenness more often had
higher risk sexual behaviour, but this was not the case
for those who consumed alcohol without becoming
drunk, which is in accord with what other authors have
described (Temple et al., 1993). Although the term
‘drunkenness’ was interpreted subjectively by each per-
son surveyed, it has the advantage of permitting better
identification of situations in which the effect of alcohol
may have produced a loss of control, regardless of the
amount ingested or of individual tolerance. The greater
frequency of drunkenness appears to be associated with
having more than one sexual partner (Weinstock et al.,
1993), but not to a parallel increase in condom use,
which leads to an increased risk for HIV infection or
transmission. The level of risk is heightened when the
frequency of drunkenness is at least monthly. This
association is not necessarily causal; rather, it may be
that excessive alcohol use is an indicator of life styles
involving higher risk sexual behaviour (Leigh et al.,
1994; Lowry et al., 1994; Donovan and McEwan, 1995;
Lauchli et al., 1996; Fontenberry et al., 1997). Both
weekday and weekend consumption of alcohol were
independently associated with a higher risk of sexual
transmission, but the mechanism appear differ. Those
who consume large quantities of alcohol on weekdays
use condoms less frequently (even after adjusting for
the number of sexual partners), whereas heavy weekend
drinkers are characterised by a larger number of sexual
partners. This distinction could be due to the existence
of cultural differences and modes of behaviour between
the two groups, since weekday use has been the tradi-
tional pattern in Spain, whereas excessive consumption
limited to the weekends is a more recently introduced
pattern, largely due to Northern European influence.
Increased risk for HIV infection has been described
among cannabis users in high risk groups (Van
Griensven et al., 1987). In the present survey the associ-
ation of cannabis use with sexual behaviour was similar
to that of excessive alcohol consumption. So far as we
know, this effect has not been described in general
population studies. It may be explained by certain
life-styles that combine a greater number of sexual
partners and particular patterns of drug or alcohol use.
Opiate users are characterised by greater condom use
with casual partners, which may be due to their height-
ened perception of the risk of acquiring or transmitting
HIV, especially among injectors. Some studies have
reported that drug injectors who are HIV positive use
condoms more often than those who are HIV negative
or who do not know their serologic status (Ruiz et al.,
1996; Bravo et al., 1999).
The results of the present study may be subject to
some limitations which should be kept in mind. The
association between substance use and sexual behaviour
has been established at the level of individuals, not of
events. This makes it difficult to detect how substance
use directly effects changes in sexual behaviour and to
distinguish this from risk-taking life-styles (Leigh et al.,
1994; Stall and Leigh, 1994; Fontenberry et al., 1997).
In any case, individuals who consume alcohol in
excess or who use cocaine or cannabis have a higher
risk of HIV infection or transmission than other per-
sons in the population with the same sociodemographic
characteristics. This should be kept in mind, because
only by understanding these life-styles will it be possible
to find ways to promote the acceptance of prevention
measures in these groups. The higher frequency of drug
and excessive alcohol use among men, single persons,
younger people, and those with a higher educational
level may partly explain why these characteristics are
also associated with higher risk sexual behaviour
(Castilla et al., 1998).
The use of other drugs (inhalants, amphetamines,
ecstasy, hallucinogens or opiates) was not significantly
associated with higher risk sexual behaviour. For the
less frequently used drugs, this may be due to a lack of
statistical power. Furthermore, the same individuals
often use more than one type of substance, all of which
may make it more difficult to detect possible
associations.
 J. Castilla et al. / Drug and Alcohol Dependence 56 (1999) 47–53
In summary, cocaine and cannabis use, and excessive
alcohol consumption are independently associated, with
varying characteristics, with certain types of higher risk
sexual behaviour for HIV infection, which may be due
to the direct effect of these substances on sexual be-
haviour, or to specific characteristics of the life-styles
which give rise to these types of consumption. In either
case, HIV prevention programmes targeted at popula-
tion groups in which there is frequent consumption of
psychoactive substances should consider specific strate-
gies to help these persons resist abandoning safe sexual
behaviour and to reinforce the use of condoms when
they are under the influence of such substances.
Acknowledgements
The National Household Survey analysed in this
study was supported by the Government Office of the
National Plan on Drugs. This work was supported in
part by a grant (Comunidad de Madrid 07/069/96).
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