Lifetime commercial heterosexual behavior among HIV negative elderly men from rural Chengdu, China: a modified knowledge-attitude-practice perspective

Benefiting from a scale-up of antiretroviral therapy (ART) and prevention of mother-to-child transmission in the past two decades, annual incidences and mortality rates of human immunodeficiency virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) have been declining [1, 2]. The declining leads to ambitious calls to end the HIV/AIDS epidemic as a public health threat by 2030 [3]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) proposed the “90–90-90 targets”, which aims to have 90% of people living with HIV (PLHIV) knowing their status, 90% of those diagnosed receiving sustained ART, and 90% of those receiving ART achieving viral suppression by 2020 [4].

China is facing big challenges to achieve the “90–90-90 targets” [5, 6]. One of the biggest challenges is that the HIV prevalence of elderly (≥50 years old) men has been steadily increasing, mainly through the sexual transmission route [7‐12]. Due to immune functional decline and increased vulnerability to infections [13], HIV infected elderly men quickly progress into AIDS even deaths [9, 13]. Being considered as sexually inactive [14], elderly men had been excluded from the priority of HIV/AIDS prevention programs [15‐18], and are not recognized and listed as a key HIV prevention group until 2017 for the first time in China [19]. On one hand, current elderly men are from 20 to 50-year-old group, who are previously sexually active and might be HIV infected as clients of female commercial sex workers (FCSW) [20‐25] and men who have sex with men (MSM) [26‐30], especially when they migrate [31‐33] but not detected. On the other hand, they could be a newly infected group. Compared with other age groups, elderly men have minimal knowledge about HIV [34], condom use among them is even lower [25, 35, 36].

Located in the southwest of China, Sichuan is one of the few provinces heavily affected by the HIV/AIDS epidemic where heterosexual transmission increased from 65.3% of total cases in 2008 to 98.2% in 2019 [37]. People over 50 years old in Sichuan accounted for less than 5% of HIV/AIDS cases in 2005, but over 40% in 2017, and 59.2% in 2019, meanwhile the proportion of elderly men in the population is less than 40% [5, 37, 38] .One of fifth PLHIV in Sichuan are from Chengdu [5, 37], the capital city. Based on case report system at population level [9, 10, 37], heterosexual transmission has been widely accepted as the major route for HIV epidemics in China. Why are elderly men involved in high risky sexual behaviors? Since the 1980s, rural-to-urban migration have been part of their lives for men from rural areas in China, and increased the possibility of being involved in high risky sexual behaviors [31‐33]. According to knowledge-attitude-practice (KAP) model [25, 34‐36, 39, 40] which has been applied in HIV prevention since 1990s, the hypothesis flows are the following: elderly men are involved in high risky sexual behaviors because they don’t believe these behaviors are highly risky. Why don’t they believe? Because they don’t have enough knowledge. In order to help them to avoid high risky sexual behaviors, it is necessary to give them health education to improve knowledge level. Though KAP model has been proved not as effectively as expected [25], due to their minimal knowledge about HIV [34], current comprehensive HIV prevention strategies in Sichuan is based on KAP [5] .

Sexual behaviors of elderly men in China are far from well-studied. In 2019, 1 year before 2020 when the “90–90-90 targets” are expected to be achieved, our team conducted a cross-sectional investigation to understand sexual behaviors among elderly men in Chengdu, China where HIV prevalence of them have been increasing in recent years and HIV prevalence of MSM has been consistently high [5].

Comparing with illicit drug use, high-risk sexual behaviors are more common among elderly men from rural areas in Chengdu. We conducted the investigation in Summer, and missed around 6% [15.09% (within the past 1 year) × 39.84% (other cities in Sichuan Province)] elderly men who migrated outside Chengdu. The adjusted prevalence of commercial heterosexual behavior was 11.22% [(94*11.07%+6*13.55%)/100×100%], and was underestimated by 1.33% [(11.22%-11.07%)/(11.22%)×100%].

It is understandable that single respondents were more likely to be involved in commercial heterosexual behavior. Similar with other elderly men in the world [14], most of the respondents’ sexual desire declined after the age of 50. The older, the less the respondents reported visiting FCSW, but visiting FCSW is not related to sexual desire change. This finding is in concord with the fact that visiting FCSW is not only to fulfill physical needs but emotional needs also [25, 41]. People often think that the conservative attitude could be a restriction against commercial heterosexual behavior [42]. In our survey, it is true among the mild objectors who are against this behavior. Surprisingly statistics found no difference in participating numbers of the commercial heterosexual behavior between the following two groups: accepting it as a natural human behavior verses strong objection. Since the 1980s, sexual attitudes in China have changed from procreation within a family context to being an individual’s responsibility as long as there is no foreseen negative impact on the wellbeing of others or the larger society [42]. However, due to convention [42] and stigma [43], Chinese, especially elderly people, do not talk about sex [44], elderly men involving in commercial heterosexual behaviors may be too shy to admit it. It can only become more difficult to access the HIV education for them than in other age groups.

Worldwide, there is huge regional variation of high-risk sexual behaviors [45], mainly determined by structural factors, such as social and economic context [45, 46]. The greatest risk factors for commercial heterosexual behavior in this study were experiences of work out of town. Since the 1980s, rural-to-urban migration have been part of their lives for men from rural areas in China. In this study, more than half of the respondents had rural-to-urban migration experience. They were sexually active migrating alone [47, 48], easy to be involved in high-risk sexual behaviors [27, 31]. Their first visit to FCSW mostly happened during their migration. Visiting FCSW was cheap and easy to get access. No one used condoms consistently, mainly because of lack of skills and knowledge. Condom in China has been used mainly for contraception, meanwhile the main contraception method among married couples were intrauterine device (IUD) for women [49]. When they were young, respondents did not take major responsibility for contraception, neither did they have too much chances to learn how to use condom, someone even never used condom in their lifetime. Moreover, carrying condom in brothels is taken as an evidence for visiting FCSW in China where sex work is illegal [49], which hold elderly men from initiating condom use when visiting FCSW.

In this study, receiving HRHE through mass media,which cover all groups of population [39] and has been part of the systematic HIV prevention [5], helped elderly men avoid visiting FCSW. Health facilities have played an important role in improving elderly men’s HIV knowledge, but been far from success. In terms of “90–90-90 targets”, even though it is not impossible to achieve the goals of 90% of HIV diagnosed population receiving sustained ART, as well as 90% of those receiving ART be viral suppressed by 2020, it is very hard to achieve 90% of diagnosis rate. Not only because free HIV testing is a voluntary action in China [5], but also one of five elderly men have not even heard the term of HIV/AIDS, let alone utilizing the free test. Current HIV prevention strategies in County A succeed in reducing blood transmission route, and most elderly men are aware of blood transmission route and none use illicit drugs through injections. However, HIV related knowledge level among elderly men is very low (31.41%). There are misunderstandings about transmission routes and stigma toward PLHIV which probably hold them back from utilizing the free test [43]. When they were detected as HIV positive, it is highly possible that they had been infected for a long time. During their undetected HIV status, they would infect their sexual partners unintentionally. FCSW infected by elderly men will also infect other age group men [25, 31‐33, 50]. That is why elderly men have been listed as key groups in HIV prevention in 2017 [19].

Comparing with illicit drug use, high-risk sexual behaviors are more common among elderly men from rural areas in Chengdu. HIV related knowledge level among elderly men is very low (31.41%). Receiving HRHE from mass media and undecided and objection attitude toward commercial sex prevent elderly from being involving in commercial heterosexual behavior.

According to the results, health intervention strategies for elderly men could be the following: Health facilities continue to conduct systematic interventions, paying more attention to 50–59 years old group. Sex and condom use need to be talked in public. Working with mass media, health facilities give elderly men health education not only focusing on transmission route of HIV/AIDS, but also on knowledge and skills of condom use.