Quantitative results
We recruited and interviewed 378 CFSWs. Among them, 327 CFSWs (86.5%, 327/378) finished the survey, met the questionnaire quality requirement, and were included in the quantitative study. Of 327 CFSWs, 97 were recruited in Changsha, with 80 participants from the ART clinics and 17 via local CDC study sites, while 230 were recruited from Hengyang, with 165 participants from the ART clinics and 65 via the local CDC study sites.
Demographics and clinical characteristics
The mean age of the sample was 46.4 years. More than one-fifth of the participants had not finished nine years of compulsory education. Around one-third were migrant laborers (103/327) and 25.7% (84/327) were formally employed in enterprises. Over half of the men (191/327) were married and 27.8% (91/327) had migrated for work in the past 6 months. In addition, over four-fifths of the participants were receiving ART (Table
1).
Table 1
Demographic and HIVa-related characteristics of HIV positive clients of females sex workers in Changsha and Hengyang in 2014
Study sites |
Changsha | 97 (29.7%) | 8 (25.0%) |
Hengyang | 230 (70.3%) | 24 (75.0%) |
Age (years) |
≥ 50 | 125 (38.2%) | 14 (43.8%) |
< 50 | 202 (61.8%) | 18 (56.2%) |
Education |
< 9 years of school | 186 (56.8%) | 21 (65.6%) |
≥ 9 years of school | 141 (43.1%) | 11 (34.4%) |
Marital status |
Divorced/separated/Windowed/never married | 136 (41.6%) | 9 (28.1%) |
Married/remarried | 191 (58.4%) | 23 (71.9%) |
Occupations |
Farmer | 68 (20.8%) | 11 (34.4%) |
Migrant laborer | 103 (31.4%) | 8 (25.0%) |
Enterprises staff | 84 (25.7%) | 7 (21.9%) |
Business | 41 (12.5%) | 6 (18.8%) |
Others | 31 (9.5%) | – |
Monthly income (RMBb) |
0–999 | 92 (28.1%) | 10 (31.3%) |
1000-2000 | 92 (28.1%) | 7 (21.9%) |
2000-3000 | 87 (27.1%) | 4 (12.5%) |
> 3000 | 56 (17.1%) | 11 (34.4%) |
Last CD4 count |
< 350 | 197 (60.2%) | 27 (84.4%) |
≥ 350 | 104 (31.8%) | 5 (15.6%) |
Unknown | 26 (8.0%) | – |
Currently on ARTc | 275 (84.1%) | 27 (84.4%) |
Migrated for work in last 6 months | 91 (27.8%) | 25 (78.1%) |
HIV knowledgeable | 273 (83.5%) | – |
Knew PLHIVd on ART may infect sexual partners | 212 (64.8%) | – |
Heard of HIV before diagnosis | 81 (24.8%) | 4 (12.5%) |
Of the 327 participants, 83.5% (273/327) were HIV knowledgeable, defined as answering six or more HIV-related questions correctly out of a total ten questions. Only 64.8% (212/327) knew that PLHIV receiving ART may still infect their sexual partners. One-quarter of HIV-positive clients (24.8%, 81/327) had never heard of HIV until they were diagnosed.
Sexual behaviors, partner types and condom use
The mean age for first sexual behavior was 22.6 years. Among the 280 married or ever married participants, 44.6% (125/280) had premarital sex. The mean age for first purchase of commercial sex was 31.4 years, with a range from 16 years to 70 years. Before their HIV diagnosis, 52.0% (170/327) had ever used condoms and 27.2% (89/327) had a history of sexually transmitted infections. In the past 6 months, 20.8% (68/327) had sex with commercial sexual partners and 9.2% (30/327) had sex with casual partners. Consistent condom use over the past six months was 47.1% (32/68) with commercial sexual partners and 43.3% (13/30) with casual partners (Table
2).
Table 2
Sexual behaviors and HIVa related knowledge in the past six months of HIV-positive clients of female sex workers in Changsha and Hengyang in 2014
Had a regular sexual partner | 65.4 | (214/327) |
Had sex (past 6 months) | 63.6 | (136/214) |
Consistent condom use (past 6 months) | 64.0 | (87/136) |
Condom use at last sex | 74.3 | (101/136) |
Had sex with commercial sexual partner | 20.8 | (68/327) |
Consistent condom use (past 6 months) | 47.1 | (32/68) |
Condom use at last sex (past 6 months) | 64.7 | (44/68) |
Had sex with casual sexual partner | 9.2 | (30/327) |
Consistent condom use (past 6 months) | 43.3 | (13/30) |
Condom use at last sex (past 6 months) | 60.0 | (18/30) |
Had ever used condoms before HIV diagnosis | 52.0 | (170/327) |
Heard of HIV/AIDSb before HIV diagnosis | 75.2 | (246/327) |
Ever had STDc before HIV diagnosis | 27.2 | (89/327) |
With regular partners, consistent condom use in the past 6 months was 2.0 times higher than with commercial partners (
P = 0.021, χ
2 = 5.334) and 2.3 times higher than with casual partners (
P = 0.037, χ
2 = 4.370). There was no difference in consistent condom use between commercial partners and casual partners (
P = 0.733, χ
2 = 0.116) (Table
3).
Table 3
Condom use in the past six months and at last sex among different types of relationships of clients of females sex workers in Changsha and Hengyang in 2014
Regular vs. Commercial | 0.021* | 5.344 | 0.156 | 2.015 |
Regular vs. Casual | 0.037* | 4.370 | 0.116 | 2.464 |
Commercial vs. Casual | 0.733 | 0.116 | 0.656 | 0.198 |
Qualitative results
Participants
The age of the 32 HIV positive CFSWs ranged from 25 to 67 years. The majority were married (23/32) and had less than nine years of education (21/32). Participants reported a monthly income between 0 to over 3000 RMB, with a median monthly income of 2200 RMB (roughly $320 USD), which is the average income of most middle-income positions in China. In the past 6 months, eight participants had sex with FSWs or casual partners, nine had sex with wives, and one had concurrent partners (Table
1). Several general themes were identified through the qualitative assessment, including participants’ feelings and beliefs towards extramarital sexual behavior; sexual relationships with different types of partners; and condom use during sexual relations with community sex workers. Table
4 displays these findings in relation to condom use. Quotes were chosen to be representative of the emerging themes and provide authenticity to the results.
Table 4
Factors influencing consistent condom use by partner type based on findings from a qualitative survey amongst 32 HIV positive clients of females sex workers in Changsha and Hengyang in 2014
✓ Negative HIVa status of sexual partners; ✓ HIV disclosure; ✓ Good relationships; co-infection knowledge; ✓ Feelings of responsibility; ✓ Have sex with regular sexual partners; ✓ Good conscientiousness and quality; ✓ Sex behavior counseling and education | ✓ HIV non-disclosure; ✓ Bad relationships; ✓ Condom reduce sex pleasure; ✓ Alcohol use; ✓ HIV stigma; ✓ Lack of consciousness to protect others | ✓ Co-infection knowledge; ✓ Good conscientiousness and quality; ✓ Sex counseling and education; | ✓ Alcohol use; ✓ Condom reduce sex pleasure; ✓ Lack of consciousness to protect others ✓ Familiar with the sexual partners; ✓ HIV positive status of sexual partners; ✓ Discrimination of FSWsb |
Almost all participants reported that extramarital sexual behavior, including sex with both commercial and noncommercial partners, was popular among their social networks. Participants frequently referred to extramarital sex as “going out to play” (qu waimian shua), that it was an act of fun without responsibility, that others in their circle were also participating in. One construction businessman who lived in nearby Shaoyang city but received ART in Hengyang reported: “Almost 50% of men in Shaoyang have gone to massage parlors or other sex service venues. In my circle of friends [in architecture and real estate], it’s 100%. It’s a trend, and sometimes I also invite them to banquets” (code No. 006, 47 years). Extramarital sexual behavior was perceived positively among peers, serving as a means of conversation and gloating. One tour bus driver explained, “Friends like to talk about those things [meaning casual sex], when they get together. It seems extraordinary if he had sex with several women, and is a thing worth boasting about” (code No. 014, 41 years).
Participants reported various motivations for having extramarital sex; including meeting their physiological needs; to add excitement to a monotonous life; peer pressure; or as part of banquets where business partners build relationships through dining, drinking, and engaging in sex with FSWs. Some participants also reported extramarital sex behavior signaled men’s social status and wealth, as it reflected that he had enough money to afford the expenses of his mistress. “As the saying goes, ‘men become bad as soon as they have money’. It’s true, if I didn’t have money, I wouldn’t have spare money to go out to play, it’s related”, a businessman reported (code No.012, 48 years).
Extramarital relationships were seen as acceptable because they were not seen as affecting a man’s ability to fulfill his family obligations, which were the most important. A taxi driver stated: “[extramarital sex] is very normal. I don’t think it matters, after all, it is loveless and it’s separate from your family responsibility” (code No.002, 40 years). A business man who had a casual partner also reported: “I am a man responsible for my family, my wife didn’t abandon me when I was sick, so when I go out to play, if something happens in my family, I must go home if my family gives me a call. Nothing is more important than family” (code No.005, 34 years).
Sexual relationships with different types of partners
Though participants knew using condoms could prevent HIV transmission, many CFSWs reported that after becoming diagnosed with HIV, they stopped having sex with their wives as they saw abstaining from sex with their wives as essential to prevent infection. One participant stated that “my wife is negative, I am afraid of infecting her, this disease is too terrible, I can’t transmit it to her” (code No.008, 58 years). Participants reported a lack of partners and an inability or unwillingness to have sex with their regular partners as important reasons for having sex with FSWs. “Now, I can’t sleep with my wife, she doesn’t have the disease, she is afraid and she does not dare to be with me. When I want [to have sex], I can only spend some money and go out [to find FSWs]” (code No.001, 47 years). In addition, participants viewed FSWs as viable sexual partners because of their HIV infection: “This disease has produced a huge shade in my heart. To put it simply, if I didn’t have this disease, I will look for a normal girl, but the fact is that I’m HIV positive. How can I let off [my libido]? I go out and look for one [FSW]” (code No.007, 33 years).
Two participants reported having casual, non-commercial partners. An unmarried young man who had broken up with his girlfriend before his HIV diagnosis did not feel ready to date after becoming infected. He felt hopeless, as he thought no girls would be willing to be his girlfriend or marry him if they knew he was infected with HIV. In order to fulfill his sexual needs, he found one-night lovers on a popular instant messaging app. A married man found an HIV-positive partner with whom he could share feelings, as he felt that his status produced a barrier to intimacy with his HIV-negative wife. He initiated a relationship with a woman he had seen at an ART clinic because he wanted a partner who also had the disease to communicate with.
Condom use in HIV positive CFSWs’ sexual relationships
Table
4 presents models for consistent condom use with different types of partners.
After being diagnosed, married participants used condoms consistently with their HIV negative spouses. “I try my best not to have sex with my wife, she doesn’t have this disease, if we have sex, we use condoms 100 percent. She didn’t abandon me when I was totally helpless, so I can’t betray her” (code No. 005, aged 34). The only participant who did not use condoms with his wife concealed his status from her, and did not know her HIV status. He explained after his first wife died, he remarried but he and his second wife did not have a strong emotional attachment.
With FSWs, participants reported they used condoms consistently to avoid infecting others. The one participant who never used condoms reported that he usually went to bath houses or massage parlors one to two times monthly, which had been greatly reduced compared to before his HIV diagnosis. He explained that he did not use condoms because “FSWs don’t ask me to use condoms, and I feel uncomfortable when using condoms. I didn’t like it” (code No. 022, 54 years). One participant who consistently used condoms described the motivations of PLHIV who engage in unsafe sexual behavior: “Human beings are all selfish, FSWs are not family. For me, I have a strong desire to protect my family, but when I go out to play, I don’t think too much” (code No. 007, 33 years).
Alcohol also hindered participants’ condom use, especially when drinking with friends. As a participant reported, “when you drink, you can make love for a longer time, and if you use condoms it would greatly influence your sexual pleasure” (code No. 002, 40 years). Another participant reported, “you can’t understand, when you drink with your friends, you will be indulging in the pleasure, no one will think of condoms” (code No. 007, 33 years).
Condom use with FSWs was also framed as a matter of conscientiousness (liangxin) and overall quality of the individual (suzhi). A divorced man reported, “I can’t understand why people don’t use condoms after knowing they are infected with HIV. Because to be human, you must at least follow your conscience” (code No. 014, 41 years). Another participant noted, “a man who has liangxin and morality and a man who has suzhi, he will restrain his own behavior after becoming infected with HIV, just like me, I am very careful when I am with my ‘friend’” (code No. 020, 37 years).
The results of this qualitative study add context and meaning to the outcomes of the quantitative assessment. The rate of condom use was two times higher among participants engaging in sexual relations with regular partners compared to commercial sex workers. The in-depth interviews conducted in this study help elaborate on potential reasons and understandings for such behaviors.