Age and regional disparity in HIV education among migrants in China: migrants population dynamic monitoring survey, 2014–2015

According to reports from the United Nations, there were 258 million international migrants and 740 million internal world migrants in 2017. The total number of migrants has increased by almost 50% since 2000, which means that in total, there are almost 1 billion people working or studying in a different place away from their hometown at the same time [1]. Pieke and Mallee (2014) described the internal migration in China as being one of the largest scale migrations in the world [2]. By 2016, the migrant population in China reached 282 million, which accounted for approximately 20% of the whole population in China [3].

Migrants have been identified as a high-risk group vulnerable to Human Immunodeficiency Virus (HIV) transmission [4]. For instance, a study of migrants in China showed that HIV prevalence increased among migrants from 0.032% in 2000 to 0.087% in 2011, compared to the 0.037% prevalence of HIV in the whole Chinese population during the same period [5]. In China, migrants are the target population in the HIV prevention strategy. Many social, economic and political factors contribute to the high risk of HIV infection among migrants, including restrictive health-related policies [6], lack of access to HIV education and services [6], discrimination and exploitation [7]. Among these factors, limited HIV knowledge among migrants remains an important but overlooked global issue that increases the risk of HIV transmission [8]. In China, low educational attainment among migrants makes them even more vulnerable to HIV transmission [9].

Previous studies have reported different proportions of migrants receiving HIV-prevention education in various populations in China [10, 11]. For instance, Yang et al. focused on male labor migrants in Xi’an city (northwest China) and found that over 40% of the participants failed to understand the concept of HIV prevention [10]. Wang et al. reported that approximately 70% of migrants in Hefei city (central China) had received HIV education and obtained knowledge of HIV prevention [11]. However, due to the scale of these studies, regional inequity has received much less direct attention. Additionally, China’s uneven regional development and cultural differences were the original sources of urban and rural divergence in HIV infection and mortality [12]. Since 1978, national public health system has experienced significant reconfigurations due to economic reforms. Currently, national policy still limits access to healthcare services in most rural areas. It remains unknown whether China’s regional variations are associated with the inequity of receiving HIV education.

With very few exceptions, existing research on HIV-prevention programs have mainly focused on young adults. However, in China the number and proportion of older migrants with HIV/AIDS have increased in recent years [13]. It is still unclear whether migrants’ age is associated with the proportion of migrants receiving HIV education. From the perspective of policy makers, more research is needed to elucidate which subpopulations would benefit the most from HIV education materials and identify age-appropriate methods of delivering HIV education.

To address this knowledge gap, we used data from a national population-based survey, the Migrant Population Dynamic Monitoring Survey (MDMS). The objectives of the study were to examine the rate and methods of HIV education by region and age group among migrants in China.

To our knowledge, this is the first study using national population-based data to examine the proportion of migrant population receiving HIV education in China. The results indicated that the rates of receiving HIV education among seven regions in China were significantly different. Regions with a higher prevalence of HIV had a higher proportion of migrants receiving HIV-related education. The east-coast region with abundant healthcare and financial resources had a relatively lower rate of receiving HIV education compared to the central and most of the western regions. We also found that regional disparity in receiving HIV was associated with HIV prevalence rates in different regions. The method of receiving HIV education varied among different age groups.

According to the Second Five-Year Action Plan to Control HIV/AIDS (2006–2010) of the Chinese central government, one of the targets for the HIV-prevention education program was to achieve over 90% coverage among the migrant population before 2010 [16, 17]. However, in our study, the average proportion of patients receiving HIV education in different regions ranged from 41.0 to 73.0%, which largely fell behind the target of the five-year action plan. Due to the existing household registration system in China, it is difficult for migrants to obtain a permanent urban household registration in the destination city, especially in the more economically developed regions, such as the east-coast region [18, 19]. Without permanent household registration, migrants in China become marginalized and have no access to HIV education, public health services, and medical insurance. This phenomenon is more common in the east-coast region of China, which partially contributes to the regional disparity in the proportion of migrants receiving HIV education. A report from the Lancet has shown that regardless of how long migrants have lived in their destination cities in China, health services were still underused and inequitably distributed among migrants [20]. More importantly, there still exists a gap between the ongoing health-care reform and the growing challenge of migration [19, 21]. Changing governmental regulations regarding entitlements to medical services and prevention programs for migrants have increased the uncertainties of local authorities regarding policy implementation and put the migrant population at risk for HIV transmission.

We found that the regions with a higher density of medical professionals (total number per 1000 population) had a lower proportion of migrants receiving HIV education. In China, a higher density of medical professionals usually correlates with more abundant healthcare and financial resources in the region. This regional disparity can be explained in two ways. First, since China’s “Four Frees and One Care” policy was issued in 2003, the Chinese government started to offer free services, such as voluntary counseling and HIV testing, antiretroviral therapy, prevention of mother-to-child transmission, schooling for HIV/AIDS orphans, and care for people living with HIV [22]. These policies resulted in a significant increase in the investment in HIV-specialized services by the central government and its capacity for HIV prevention. Large-scale HIV prevention programs were also implemented in the provinces with the highest HIV prevalence, including the southwest region (e.g., Guangxi Province and Yunnan Province) and the west-Uygur Region [23]. From 2010 to 2015, the overall budget for HIV prevention in China was 280,923 billion CNY (44,344 billion USD) (Internal report, 2017). The central government allocated HIV-specialized prevention resources based on the level of HIV prevalence in each province, GDP, and annual income per capita, which meant that provinces with higher HIV prevalence and those that were less developed had more funding from the central government to conduct large-scale HIV prevention campaigns. However, current national HIV-specialized budget index from the central government does not include HIV prevalence among marginalized subgroups (i.e., LGBT, drug users, migrant populations) as key parameters for resource allocation, which directly contributes to the inequitable allocation of HIV resources among migrants in different regions. When HIV prevalence among these subgroups does not match the overall HIV distribution, HIV resources are not allocated to those who need them the most. As a result, migrants in regions with abundant financial and healthcare resources are less likely to receive HIV education due to these regions receiving less HIV-related funding from the central government.

Additionally, due to lower HIV prevalence in more developed regions, there is little effort to control and prevent HIV among migrant populations in these regions of China. As a result, although the total number of newly diagnosed HIV adults in these regions is relatively small, migrants still account for a large proportion of the newly diagnosed HIV cases in the more developed regions. For instance, in China, the Notifiable Infectious Disease Report showed that metropolitan areas densely populated by migrants, such as Beijing, Shanghai and Guangdong Province, accounted for 31 to 42% of the newly diagnosed patients in 2016 [16].

Inequitable HIV education allocation among migrants continues to exist globally. For instance, agencies of the United Nations, including the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), will continue their work to eliminate HIV transmission and increase service coverage in eastern and southern Africa over the next 5 years [24]. However, against the backdrop of the European migrant crisis, a 2014 report from UNAIDS noted that since 2004, in western and central Europe, migrants originating from high-prevalence countries accounted for over 15% of new HIV diagnoses, suggesting possible gaps in HIV prevention services for migrants [25]. More HIV education need to be allocated to regions with large-scale floating populations (migrants, immigrants, and refugees), such as central and northern Europe and central and south Asia.

Several other issues need to be considered when interpreting our findings. First, we found that older, female migrants with lower education level and lower monthly income were less likely to receive HIV education. Similarly, a study conducted in China showed that a lower level of education was associated with poorer HIV knowledge among male labor migrants [10]. The inequality of age and gender interacts with the possibility of accessing HIV education [26, 27]. Previous studies have shown that older adults do not have as much HIV knowledge as young people [28] and that there is also a rising prevalence of HIV among older adults [13]. In addition, women are more easily isolated from HIV intervention and healthcare services due to the mode of transmission and complex cultural factors [29]. There is a need to target education efforts for older and female migrants in China.

Second, we found that methods of receiving HIV education varied among age groups. Younger migrants reported receiving HIV education via online social media and online consultation platforms. In contrast, older migrants reported receiving HIV education through traditional media and face-to-face consultations. These results are consistent with previous studies in other countries indicating differences in how younger and older age groups received HIV education [30]. This can be explained in several ways. First, many young migrants may prefer online media and consultations to in-person physician visits, since online media can provide anonymity and are much more convenient for migrants to have access to latest information [31]. Second, older adults may face a number of barriers when adopting a new technology. Some of the challenges include not being able to physically use the device. In addition, older adults may not see the added value of using technology as opposed to mainstream media [32]. Since technologies are continually evolving, the government is constantly keeping pace with technological advancements to ensure the quality of health education. Younger migrants today may prefer to receive HIV education using newer technologies. However, there is still a large proportion of older migrants receiving HIV education through traditional media, including television, radio, and bulletin boards. Therefore, providing multiple streams of HIV education, including both new and traditional media, for both young and older migrants is essential.

Our study generated new knowledge about factors associated with receiving HIV education among migrants in China. Our findings suggest significant regional disparities among migrants in China. Methods of receiving HIV education varied among different age groups. Our study findings suggest that health care resources need to be allocated to regions with large-scale migrant populations. The current funding allocation mechanisms in China may lead to an inequitable allocation of HIV resources among migrants in different regions. HIV education should be tailored to the age of migrants and should focus on female migrants with low educational and income levels.