HIV/AIDS Among Female Sex Workers in China: Epidemiology and Recent Prevention Strategies

Prevalence and Residual Risk of HIV in Volunteer Blood Donors of Zhejiang Province, China, from 2018 to 2022

Background

Blood safety levels have been significantly improved since the implementation of nucleic acid amplification technology (NAT) testing for blood donors. However, there remains a residual risk of transfusion transmission infections. This study aimed to evaluate the prevalence of HIV and its residual risk transmission among volunteer blood donors of Zhejiang Province, China, for five years after NAT implementation.

Materials and Methods

All specimens and information were collected from voluntary unpaid donors at all blood services in Zhejiang Province, China, from January 2018 to December 2022. The HIV antibody or antigen and HIV RNA were detected using enzyme-linked immunosorbent assay and NAT, respectively. The HIV residual risk transmission was calculated using the incidence or window period model.

Results

A total of 3,375,678 voluntary blood donors were detected, revealing an HIV prevalence of 9.92/100000. The HIV prevalence of blood donors in 12 blood services in Zhejiang Province was 6.11, 6.98, 7.45, 8.21, 8.36, 8.94, 9.04, 9.66, 9.73, 10.22, 11.80, and 12.47 per 100000 donors, without statistically significant difference observed among the services (p > 0.05). The HIV prevalence of males (15.49/100000) was significantly higher compared to females (1.95/100000; p < 0.05). There was an insignificant difference in HIV prevalence among blood donors of all different age groups (p > 0.05), but the HIV prevalence in the 26-35 age group and 18-25 age group was significantly higher compared to the 36-45 age group (p < 0.05). The difference in HIV prevalence between first-time blood donors (13.65/100,000) and repeat blood donors (6.78/100,000) was statistically significant (p < 0.05). From 2018 to 2022, the HIV residual risk in blood transfusion transmission was 0.266/100000.

Conclusion

The prevalence of HIV among blood donors in Zhejiang Province, China, is associated with age, gender, and times of blood donation. The HIV residual risk in blood transfusion transmission remains low in the province, and increasing the rate of repeat blood donors is beneficial to improve blood safety.

Differences in socio-demographics status, risk behaviours, healthcare uptake and HIV/ sexually transmitted infections (STIs) between brothel-based and street-based female sex workers in Yunnan, China

BACKGROUND

Heterosexual contact is the primary mode of HIV transmission in China and commercial sex is thought to play a crucial role in China's epidemic. Female sex workers (FSWs) in China tend to be either brothel-based (BSWs) or street-based (SSWs), but few studies have investigated the differences between these important segments of this difficult-to-reach, high-risk population. Our aim was to explore the differences between SSWs and BSWs in terms of socio-demographic characteristics, sexual and risky practices, HIV/STI-related knowledge, health services, HIV/STI prevalence and other aspects.

METHODS

A cross-sectional survey was conducted in Yunnan Province of China in partnership with a local FSW-friendly non-governmental organization. Face-to-face interviews using a structured questionnaire were conducted to collect data on socio-demographic characteristics, sex work history, sexual behaviours, HIV/STI-related knowledge, HIV testing history, and healthcare services uptake. Blood samples were taken for HIV and syphilis testing, and urine samples for gonorrhea and chlamydia testing. Descriptive statistics were used to evaluate differences between SSWs and BSWs.

RESULTS

A total of 185 BSWs and 129 SSWs were included in the study. SSWs were older and less educated, had more dependents and more clients, lower condom use and accessed fewer healthcare services. Moreover, 37.2% of SSWs and 24.9% of BSWs were found to have HIV/STI infection. Unfortunately, the awareness related to STIs was relatively low in both groups, especially SSWs.

CONCLUSIONS

Our study provides evidence that confirms the disproportionately high vulnerability of SSWs to HIV and other STIs, underscoring the urgent need for the Chinese health and public health sectors to prioritize outreach to SSWs. Awareness and educational programs, condom distribution, testing and health check-ups should be included in a comprehensive strategy for HIV/STI prevention in this high-risk population.

The effects of social networks on HIV risk behaviors among Vietnamese female sex workers: a qualitative study

INTRODUCTION

Female sex workers (FSWs) experience heightened vulnerability to HIV and other health harms, and cross-border FSWs face additional challenges due to language issues, higher mobility, and weaker negotiation skills. Given the critical role of social network factors in HIV transmission, it is imperative to explore the social network characteristics of Vietnamese cross-border FSWs in China to enhance AIDS prevention and control.

METHODS

We conducted semi-structured interviews with 22 Vietnamese FSWs in Hekou County, Yunnan Province from May to July 2018. The samples were selected using a purposive sampling strategy and stopped when reached theoretical saturation. Data collection and analysis were conducted iteratively to identify themes within the data. Participants reported their social relationships and how these relationships affected their HIV risk behaviours. All the interviews were recorded, transcribed verbatim, and reviewed. Thematic analysis was used to analyse the data.

RESULTS

Among 22 Vietnamese FSWs, the median age was 23.5. Concerning social networks, interviews revealed that their social networks were composed of three components: Workplace networks (customer, boss, colleague), Hometown networks (spouse or boyfriend, family member, fellow villager), and Social institutions networks (Chinese social institutions network, Vietnamese social institutions network). None of these networks can simply support or hinder Vietnamese FSWs' preventive high-risk HIV behaviours, and the impact is achieved through each network's ways. Within the workplace network, the predominant influence is the ascendancy-submissiveness dynamic that exists among customers, bosses, and VFSWs. In the hometown network, familial responsibilities emerge as the principal factor impacting VFSWs. Meanwhile, within the social institution network, pivotal roles are played by the Chinese CDC and the Vietnamese government in the dissemination of HIV knowledge.

CONCLUSIONS

The social networks of Vietnamese female sex workers exert a dual impact on high-risk HIV behaviors. Interventions should be designed and tailored to address the specific contextual factors and challenges associated with social networks among cross-border FSWs in China and other similar settings.

The Update of HIV-1 Prevalence and Incidence and Spatio-Temporal Analyses of HIV Recent Infection Among Four Sub-Groups in Sichuan, China During Surveillance Period Between 2016 and 2022

Background

Sichuan Province has gradually become a hot-spot for HIV/AIDS. Little is known about the HIV-1 incidence and prevalence among four sub-groups since 2015. Meanwhile, the distributions of hot-spot areas related to recent infection cases that indicate current transmission among the four subgroups are also rare.

Objective

The main purpose of this study was to assess the HIV-1 prevalence and incidence and to visualize the distributions of hot-spot areas of current transmission among four subgroups (people who inject drugs, male STD clinic attendees, female sex workers and men who had sex with men) during the surveillance period in Sichuan province between 2016 and 2022.

Results

Of the 267,617 individuals, 2158 HIV-positive samples were tested with Lag-Avidity EIA, among which 493 samples were identified as recent infections. Among people who inject drugs (PWID), both HIV-1 prevalence (from 1.41% to 0.34%) and incidence (from 0.03% to 0.140%) showed a significant decreasing trend. Among men who had sex with men (MSM), female sex workers (FSWs), and male STD clinic attendees, HIV-1 prevalence indicated significant decreasing trends, whereas HIV-1 incidence showed no significant changes. Spatial analysis demonstrated the formation of hot-spots and clusters of current transmissions sharing regional differences, mainly concentrated in the southeast, and most of these were consecutive hot-spots.

Conclusion

The prevention and control were efficacious and persistent. However, among the other three subgroups, there is a need for a regional cooperative in prevention and control approaches and collaborative research in many aspects.

Prevalence and trend of gonorrhea in female sex workers and men having sex with men in China: a systematic review and meta-analysis

OBJECTIVES

This systematic review was conducted to estimate the respective prevalence of gonorrhea among two high-risk populations in China and determine the epidemiological features of gonorrhea in them.

STUDY DESIGN

Systematic review.

METHODS

PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang databases were searched to identify studies published between January 1, 1990, and October 31, 2022, with gonorrhea prevalence tested by polymerase chain reaction among female sex workers (FSWs) and men who have sex with men (MSM). Meta-regression and subgroup analyses were used to investigate potential factors of heterogeneity across studies. Trend analysis of prevalence was conducted by the Jonckheere-Terpstra method.

RESULTS

We identified 88 prevalence data points from 49 studies in China, with 30,853 participants of FSWs and 5523 participants of MSM. Pooled prevalence of gonorrhea among FSWs and MSM were 6.9% (95% confidence interval: 4.6-9.7%) and 2.5% (95% confidence interval: 1.5-3.7%), respectively. The subgroup analyses showed there were period, regional, and specimen collection methods diversities among FSWs, and diversities of the regions and specimen collection anatomical sites were found among MSM, in which the prevalence of rectum and pharynx was significantly higher than the urethra. A decreasing trend in the prevalence of gonorrhea was seen among FSWs (z = -4.03) from 1999 to 2021, not found for MSM in China.

CONCLUSION

The prevalence of gonorrhea is high in two high-risk groups in China, with extragenital infections requiring particular attention. The findings of this study will provide evidence to formulate national policy and guidance for gonorrhea prevention and control.

Sexualized Drug Use Among Female Sex Workers from Eight Cities in China: A Cross-Sectional Study

There is a rich literature on sexualized drug use (i.e., drug use before or during sex) for men who have sex with men but less data from female sex workers (FSW), particularly from low- and middle-income countries. We describe the sexual and reproductive health outcomes in FSW reporting sexualized drug use. In 2019, we conducted a cross-sectional study in eight cities from seven provinces in China. We recruited FSW through community organizations working with sex workers and included those aged 18 years or above, exchanged sex at least once for money or goods in the past three months, and had traded sex for longer than a year. Multivariable logistic regression models were used. In total, 650 women participated: average age was 38.8 years (SD 10.2), 57.1% reported a monthly income over 5000 RMB ($USD 707), and 12.8% completed high school or above. Among participants, 65 (10.0%, 95% confidence interval (CI) 7.8-12.6) reported a history of sexualized drug use. Compared to FSW who never reported a history of sexualized drug use, FSW who reported a history of sexualized drug use had greater odds of working for a manager compared to being self-employed (adjusted odds ratio (AOR) 4.04, 95% CI 2.12-7.69), work in a sauna (AOR 2.43, 95% CI 1.09-5.41), charging a higher price for vaginal sex (AOR 2.15, 95% CI 1.14-4.06), and ever diagnosed with STIs (AOR 4.51, 95% CI 2.61-7.80). One in ten FSW reported sexualized drug use. Although they had similar risk profiles in terms of consistency of condom use and reproductive health outcomes, these women were more likely to report past STIs than those who reported no sexualized drug use. Health workers who work with substance users should devote attention to the sexual practices of their clients to make sure that they have safer sex.

Trends and associated factors in the uptake of HIV testing among female sex workers in Sino-Vietnam border areas in Guangxi, China: a cross-sectional study

Background

HIV testing is a primary prevention strategy against the HIV epidemic and an entry point for HIV/AIDS-related care, prevention and treatment. This study aimed to estimate the uptake of HIV testing among Sino-Vietnam female sex workers (FSWs) in Guangxi, China, from 2016 to 2018, and to identify the factors influencing HIV testing uptake.

Methods

A cross-sectional survey was conducted among FSWs in two Sino-Vietnam border cities of Guangxi, China. The survey was conducted through face-to-face interview, the data were collected by a structured questionnaire, and HIV-1 infection was detected simultaneously. Logistic regression analysis was used to determine the factors associated with uptake of HIV testing.

Results

In total, 4565 Chinese local FSWs (CL-FSWs) and 636 cross-border migrant Vietnamese FSWs (CMV-FSWs) were recruited into this study. HIV-1 prevalence in CL-FSWs and CMV-FSWs was 0.70% and 3.14%, respectively. The rate of self-reported uptake of HIV testing in CL-FSWs and CMV-FSWs was 54.56% and 45.44%, respectively. The rates of self-reported uptake of HIV testing declined in both groups from 2016 to 2018. Logistic regression analysis indicated that a number of factors, including socio-demographic characteristics (age < 35 years, higher education, location in Chongzuo City), behaviour factors (having received free AIDS education, condom distribution services and peer education services, high risk sexual behaviours such as inconsistent condom use, having regular commercial sexual partners, etc.), psychological factors (perception of vulnerability to HIV/STIs, perception of risk for HIV infection) were the factors significantly related to uptake of HIV testing.

Conclusion

In recent years, the rate of HIV testing uptake among Sino-Vietnam border FSWs in Guangxi, China was low, which may be an important reason for the high HIV-1 prevalence among FSWs in the region. A number of factors were identified to be associated with HIV-1 testing uptake, suggesting that HIV testing prevention strategies in this region could include accelerating AIDS education training, raising personal awareness of HIV testing, and improving accessibility of HIV testing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07459-3.

Mindfulness, psychological distress, and somatic symptoms among women engaged in sex work in China

Women engaged in sex work (WSW) in China encounter numerous disadvantages (e.g., exposure to violence) and have substantial risk for psychological distress and somatic symptoms. Intervention literature has attended to mindfulness, which is a protective factor for psychological outcomes, and its influences can further improve physical health. However, mindfulness has not been well studied in WSW. We aimed to examine the association among mindfulness, psychological distress, and somatic symptoms among Chinese WSW. Data were collected from 410 WSW in Guangxi, China, using an anonymous, self‐administered survey evaluating demographics, mindfulness, psychological distress (i.e., depression, loneliness, and perceived stress), and somatic symptoms (i.e., pain, cardiopulmonary, and gastrointestinal/fatigue symptoms). Structural equation modeling was utilized for data analyses. Mindfulness was negatively associated with psychological distress and somatic symptoms. Psychological distress was positively associated with somatic symptoms. Psychological distress mediated the association between mindfulness and somatic symptoms. Mindfulness appears to be a protective factor for psychological distress among WSW, and such an effect is further influential to their somatic symptoms. Our findings add to the growing literature on mindfulness, suggesting that mindfulness‐based interventions could be beneficial for WSW. Future research should explore other cognitive factors underlying the psychosomatic mechanism of mindfulness.

Analysis of Related Factors of Mother-to-Child Transmission of AIDS and Evaluation of Measures to Prevent Mother-to-Child Transmission

AIDS is still a major public health facing the world. With the implementation of AIDS prevention projects and the continuous maturity of technology, more and more HIV-positive women choose to have children. However, the children born to these women are a special group. Exposure to HIV and antiviral drugs during the fetal period can increase the success rate of children's elimination of the mother, which is worthy of attention and research. This article focuses on the analysis of the related factors of mother-to-child transmission of AIDS and the evaluation of mother-to-child blocking measures, using the method of field research to conduct experiments on AIDS patients in this city who are pregnant and provide them with antidrug treatment and some barrier measures. Then, the mother-to-child transmission rate was recorded, and the experimental results showed that the antidrug treatment plan is related to mother-to-child transmission. After antidrug treatment, the transmission rate of single-drug treatment is reduced by 5%, and the transmission rate of combined drug treatment is reduced by 10%. It can be seen from this that antidrug treatment is an effective measure to block mothers and babies.

Research Progress in the Epidemiology of HIV/AIDS in China

After thirty-two years since the first domestic outbreak of human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) among injection drug users (IDUs) and almost two decades of comprehensive response efforts by the Chinese government, HIV/AIDS remains a major public health problem. The increasing burden of HIV/AIDS and comorbidities, the emergence of new HIV subtypes and/or circulating recombinant forms and drug mutations, the changing transmission networks, and the urgency of immediate antiretroviral therapy initiation upon an HIV diagnosis are increasingly challenging and altogether likely to have significant impact on the HIV epidemic in China. Upon the call for the global AIDS response to end AIDS by 2030, China needs to develop an innovative and pragmatic roadmap to address these challenges. This review is intended to provide a succinct overview of what China has done in efforts to achieve the global goal of ending AIDS by 2030 and the recently proposed "95-95-95-95" target (95% combination prevention, 95% detection, 95% treatment, 95% viral suppression), and to summarize the most recent progresses in the epidemiological research of HIV/AIDS in China with the aim of providing insights on the next generation of HIV control and prevention approaches and to shed light on upgrading the national strategy to end AIDS in this country.

Epidemiological profile and molecular genetic characterization of HIV-1 among female sex workers and elderly male clients in Guangxi, China

The HIV/AIDS prevalence in female sex workers (FSWs) and elderly male clients is increasing in Guangxi, China, but the transmission relationship between them remains unclear. This study aims to illuminate the transmission network between FSWs and elderly male clients using molecular epidemiological analyses. Phylogenetic analysis indicated that CRF01_AE was the dominant strain, followed by CRF07_BC and CRF08_BC in both groups. Multivariate logistic regression analysis indicated that viral loads of 50 to 1000 copies/mL, immunological treatment failure and CRF07_BC were risk factors for entering the transmission network. Transmission network analysis showed that CRF07_BC tended to form large clusters, whereas CRF01_AE tended to form multiple but small clusters. Two groups of 11 FSWs and 169 clients were intricately intertwined. Spatial analysis demonstrated the formation of hotspots and clusters of transmission sharing regional differences. In conclusion, our study provides direct genetic evidence of transmission linkages between FSWs and elderly male clients. Although the CRF01_AE subtype was still the predominant subtype in the region, the higher degree and larger clusters found in CRF07_BC illustrate a rapid and intensive uptrend, which is expected to increase its prevalence in the region in the future.

The Enigma of the Human Immunodeficiency Virus (HIV) Epidemic in China

Nearly 17 years ago China launched its National HIV/AIDS Response Program, yet the epidemic still is not slowing. New cases and new deaths increase every year—in 2005, 40 711 people living with human immunodeficiency virus (HIV; PLWH) were diagnosed and 5729 died, whereas in 2019, 148 598 PLWH were diagnosed and 31 522 died. Moreover, the estimated PLWH population in China has risen to >1.25 million. However, epidemic data are worryingly complex and difficult to interpret, presenting challenges to the redirection and refocusing of efforts toward achievement of control. Here we present three “windows” into China’s epidemic data. From these viewpoints, it appears we still do not know how much infection exists, how much transmission is occurring, and in what contexts transmission happens. The enigma that is China’s HIV epidemic must be better understood. A new research agenda must be developed and executed if we are to change the future of HIV in China.

A thematic analysis of experiences of HIV risks among female sex workers in the Yunnan-Vietnam Chinese border region

Background

The Yunnan province is located near the “Golden Triangle” border region between China, Myanmar and Thailand, which has the highest HIV/AIDS prevalence in China. Female sex workers (FSWs) in the Yunnan province are highly vulnerable to HIV infection. The objective of this study was to examine the experiences of FSWs in the Yunnan to better understand the risk of infection and the potential for transmission of HIV.

Methods

Semi-structured interviews were conducted between May 2018 and June 2018 with 20 FSWs recruited in Hekou County, Yunnan Province, China. Thematic analysis was conducted to identify themes that highlighted increased exposure of FSWs to the risk of HIV infection and transmission.

Results

The findings showed that FSWs’ primary source for HIV information was gynecologists, with few visiting the local HIV charity Red Ribbon. FSWs reported infrequent visits for check-ups with some seeing a gynecologist once a year. FSWs felt that the onus was on them to prevent STI/HIV infection by using a condom during sex, regardless of their ability to negotiate use. FSWs were also reluctant to see a gynecologists for treatment. Instead, they resorted to douching as a way of preventing HIV/STIs and treating vaginal health problems, such as leucorrhea. Most FSWs worked without the influence of alcohol and drugs. A small number of FSWs reported heroin addiction and injecting drug use.

Conclusion

The findings suggest a need for innovative HIV prevention strategies among FSWs and their clients in the Chinese border region. Governmental agencies should continue to implement practical strategies in terms of HIV prevention education and condom use through tailored interventions that are localized. Such strategies should include localized tailored interventions that dispel myths about douching as a method of HIV/STI prevention and incorporate a mobile outreach approach, similar to the ‘roadside restaurant’ outreach that has been successful in rural China.

Changing trends of HIV, syphilis, HCV infections and behavioural factors among female sex workers in Chongqing, China: findings from six serial surveillance surveys

OBJECTIVES

To explore the prevalence and changing trends of HIV, syphilis, hepatitis C virus (HCV) infections and risk behaviours among female sex workers (FSWs) and to provide reference and theoretical basis for formulating targeted interventions.

DESIGN

Six consecutive cross-sectional surveys.

SETTING

Chongqing, China.

PARTICIPANTS

FSWs were included if they (1) were aged ≥16 years, (2) provided commercial sex for money or goods during the previous month and (3) were willing to participate in the survey and could provide verbal informed consent. This study included 16 791 of 16 810 participants recruited between 2013 and 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The prevalence of HIV/syphilis/HCV infection.

RESULTS

The HIV and HCV prevalence among FSWs in Chongqing was stable during the study period, but the prevalence of syphilis had an increasing trend, particularly among low-tier and middle-tier FSWs. Improvements in HIV-related knowledge, condom use, injecting drug use and participation in HIV-related services were observed. However, no change was found in the prevalence of drug use. HIV infection was correlated with no condom use in the last commercial sex (adjusted OR (aOR) 3.48, 95% CI 1.90 to 6.37) and syphilis infection (aOR 4.88, 95% CI 1.95 to 12.18). Syphilis infection was correlated with inconsistent condom use (aOR 1.30, 95% CI 1.02 to 1.65), HIV infection (aOR 5.88, 95% CI 2.40 to 14.41), HCV infection (aOR 7.68, 95% CI 4.37 to 13.49) and sexually transmitted infection (STI) diagnosis in the past year (aOR 3.81, 95% CI 2.40 to 6.03). HCV infection was associated with injecting drug use (aOR 8.91, 95% CI 4.45 to 17.86) and syphilis infection (aOR 7.88, 95% CI 4.49 to 13.83).

CONCLUSIONS

Comprehensive interventions targeting FSWs, particularly low-tier and middle-tier FSWs, should be increasingly implemented to prevent and control HIV, syphilis and other STIs.

Sexual and reproductive health correlates of polysubstance use among female adolescents who sell sex in the southwest of China

Background

Substance use and adverse sexual and reproductive health (SRH) outcomes continue to be significant threats to female adolescents’ health and wellbeing, particularly to these marginalized subpopulations. Our research aimed to tackle knowledge gaps regarding the prevalence of concurrent substance use including alcohol, tobacco, illicit drug among Chinese adolescent female sex workers (AFSWs), while to assess the correlates between substance use and SRH risks; the needs for comprehensive SRH services were also examined in this study.

Methods

A cross-sectional study enrolled 310 AFSWs aged 15–19 years by using cluster sampling method in Kunming, China. Descriptive analysis was employed to characterize the participants who were regular-alcohol users, regular-tobacco users, illicit drug users and polysubstance users. Multivariable logistic regression analysis was performed to detect the SRH correlates of regular-alcohol use, regular-tobacco use, illicit drugs and polysubstance use respectively.

Results

There is a high prevalence of regular-alcohol drinking (83%, 257/310) among AFSWs, with 44% (136/310) smoking cigarettes regularly and 9% using illicit drug (27/310) in the past year. In multivariate analysis, AFSWs who had middle and high school education, had higher monthly income, experienced of sexual and gender based violence (SGBV) and prior abortion, and regular-tobacco smoking were associated with increased odds of regular-alcohol drinking; engaging in unprotected sex while drunk, having STIs symptoms and using illicit drugs were significantly associated with regular-tobacco smoking; while AFSWs who had an illicit drug using- intimate partner, experienced forced sexual initiation, accessed unsafe medical providers for STIs treatment were associate with increased odds of illicit drug use. Moreover, 35% (105/298) AFSWs sought unsafe medical care for STIs treatment, or no treatment at all, among them, majority were using polysubstance (87%; 91/105).

Conclusions

Our findings reveal combined threats of substance use to AFSWs’ SRH and wellbeing in China, this study emphasises that the coordinated efforts are needed to integrate SRH promotion and harm reduction service across sectors, and not only fragmented measures. An effective response should include an agreed framework, indicators and targets supported by political will, solid leadership and policy reform to deal with AFSWs’ overlapping vulnerabilities in a systematic way.