Changing sexual attitudes and behaviour in China: implications for the spread of HIV and other sexually transmitted diseases

In Imperial China sexual behaviour was regarded as an indispensable activity to reach harmony with the universe, through the unity of the interaction of two opposing forces: yin and yang. Sexual intercourse was accepted when linked to procreation within a family context, while an individual's sexuality was not considered important. Homosexuality was tolerated although not advocated, while masturbation was denounced. Since the One Child Family and Open Door policies in the 1970s and the economic reforms of the 1980s, attitudes towards sexuality in China have changed. Premarital sex has become widely accepted among young people and people in China are now more tolerant toward extramarital sex. Nowadays young people consider that love should dominate marriage and the quality of an individual's sex life is currently more valued than it used to be. Attitudes towards masturbation have become more tolerant and though homosexuality has been hidden by society for a long time, in recent years it has begun to be considered as a legitimate lifestyle choice. Attitudes towards sex and sexual behaviour have become recognized as an individuals' responsibility as long as no offence occurs against society or the interests of other individuals, resulting in the recognition of diversity of sexual behaviour. As part of the changing attitudes to sex and sexual behaviour, heterosexual transmission is becoming the most important route of HIV transmission in China. This is complicated by the internal migration of an estimated 120 million labourers moving from the countryside to the cities as the result of economic reforms, most of whom are sexually active young men. Unless addressed directly, these factors may add to the estimated 300,000 HIV-infected Chinese, further fuelling an already rapidly spreading epidemic. The ramifications of the Chinese HIV epidemic will not only be felt within China, but also within the surrounding Asian countries thereby fuelling the HIV pandemic.

Changing patterns of extramarital conceptions in the Czech Republic, 1960-93

Patterns of reproduction associated with extramarital conception are examined using data on non-marital births, marital births occurring during less than 8 months after marriage, and spontaneous and induced abortions experienced by unmarried women. Trends in the incidence and demographic outcomes of conceptions resulting from extramarital coitus are analysed by means of age-specific probabilities of becoming pregnant outside marriage; and of terminating such a pregnancy by abortion, by legitimating it through marriage before confinement, or by having a baby while remaining unmarried. Substantial increases in the proportion of extramaritally conceived pregnancies leading to non-marital births are detected for the period since the late 1980s, and ascribed mainly to rising levels of unmarried cohabitation. The demographic effects of the post-1989 transition from state to market economy are discussed.

Heterosexual behaviour and condom usage in an urban population of Delhi, India

A survey conducted among the lower-class urban population of Delhi, India to describe the heterosexual behaviour, condom usage and awareness about STDs/AIDS revealed that 4.4% respondents had sex outside/before marriage. Female commercial sex workers, friends and neighbours were the important sexual partners. Heterosexual activity was significantly higher among males, unmarried, literates and middle/higher income groups. Almost half of those who had sex before/outside marriage never used a condom during the sexual encounter. Though only a small fraction of the population was found to be engaged in extra-/pre-marital sex, the overall impact of this may be multifold, given the nature and modes of HIV transmission. The superficial and inadequate knowledge regarding STDs/AIDS among this population, especially among those having extra-/pre-marital sex, indicates an urgent need for appropriately targeted health education and condom promotion activities in the community with an endeavour to increase awareness about STDs and HIV/AIDS and motivate people towards healthy sexual lifestyles.

Social and cultural aspects of infertility in Mozambique

Findings of an anthropological study of socio-cultural aspects of infertility among members of the matrilineal ethnic group Macua in the north of Mozambique are presented. Infertile women apply various strategies to have a child. Traditional healers are visited much more often than the modern hospital, and the explanations the infertile women themselves give for their infertility more often originated from the traditional healers than from the hospital staff. Almost all of the interviewed women commit adultery in the hope to conceive. Some of them apply fostering as a partial solution for childlessness. The Macua infertile women experience various consequences due to their infertility, of which exclusion from certain social activities and traditional ceremonies is perceived as a very problematic one. The matrilineal kinship system means that the husband and his family do not mistreat and repudiate her. Infertility must be considered as a serious reproductive health problem in Mozambique. For the long term preventive measures may be more influential than curative one. The findings of this study can be used to elaborate culturally sensitive health education programmes.

Sexual networks in Uganda: casual and commercial sex in a trading town

A longitudinal study of the sexual behaviour of high-risk men and women living in a trading town on the trans-Africa highway showed that distinct sexual networks operated within the town. Forty-eight prostitutes kept daily records for 6 months of all their sexual contacts including the occupation and place of residence of each client and the price paid. Details of 4573 sexual contacts of the women were recorded. Three classes of women were identified: (1) 20 "high-class' women who charged a mean price of over US $4/- per contact. The majority of their clients were from large urban areas of Uganda (55%) or neighbouring countries (32%)-70% were truck-drivers or their mates; (2) 18 "low-class' women, charging an average of US $0.4 per contact, who were patronized predominantly by men resident in the town (71%) who were unskilled casual workers (58%); (3) 10 women fell into an intermediate category in terms of price and the residence of their clients. Thirty-eight male potential clients were recruited in low-cost bars where some of the women worked. They provided similar details of their daily sexual contacts. All were resident in the town and 22 had occupations which were classified as unskilled. Of the 1621 sexual contacts recorded by the men 25% were with new partners.

Men, women and the trouble with condoms: problems associated with condom use by migrant workers in rural Zambia

Understanding cultural attitudes to condoms is of the utmost importance in promoting their use as a means of protection against HIV transmission. This article examines condom use in relation to what people see as the purpose of sex, what good sex entails and how this relates to ideas of being a proper woman or man. It seems that the underlying and pervasive ideal is that sex is essentially a procreative act, since an emphasis on male potency and male and female fertility often overrides anxieties about contracting HIV and other sexually transmitted diseases. Hence condom use is usually only negotiated within some short-term relationships and then not consistently. Whilst both men and women have negative attitudes to condoms, women because of their economic and ideological dependence on men are in a much weaker position to negotiate condom use.

Changes in male sexual behaviour in response to the AIDS epidemic: evidence from a cohort study in urban Tanzania

OBJECTIVE

To examine changes in sexual behaviour among men in urban Tanzania.

DESIGN

An observational cohort study among factory workers during 1991-1994.

METHODS

Data from five follow-up visits with structured questionnaire-guided interviews and biomedical data were analysed to examine trends in sexual behaviour and sexually transmitted disease/HIV among 752 men. In-depth interviews were conducted to evaluate the magnitude of reporting bias.

RESULTS

During the 2 years of observation, the proportion of men with more than one sexual partner during the month preceding the interview declined from 22.3 to 12.2%. The proportion of men reporting casual sex partners during the last month was almost halved: from 9.8 to 5.2%. The decline in the reporting of extramarital partners was gradual and pronounced. There were only minor changes in reported condom use, notably an increase in use with casual partners, and no changes in coital frequency. Data from in-depth interviews confirmed that reduction in sexual partners was the predominant change.

CONCLUSIONS

This study documents that, in response to the AIDS epidemic, changes in male sexual behaviour are taking place in urban areas in Africa. The predominant change among these men, who are predominantly married and aged over 25 years, is a reduction of the number of sexual partners, although condom use remains low.

Casual sex, extramarital sex, condom use and alcohol intake among heterosexual patients attending an STD clinic in Norway

A study excluding homosexuals was performed to study casual sex, extramarital sex, the use of a condom with a casual sexual partner and the combination of alcohol intake and casual sex among patients attending a clinic for sexually transmitted diseases (STDs). Heterosexual patients (467) received a questionnaire, and 458 were included. Men reported more (94%) casual sexual partners than did women (76%). According to a multiple logistic regression analysis a condom was used significantly less frequently in "old" respondents, those having a permanent sexual partner, those having low education, those infected with STDs (earlier STDs), those who had had more than 4 sexual partners over the last year, and those combining alcohol intake and casual sex. Intravenous drug users/prostitutes used a condom more often than did men with paid sex and "other heterosexuals". To have an effect on STD patients, innovative forms of health education may be necessary, and greater emphasis should be placed on more informal means of information, including interactive health education and communication strategies to promote positive attitudes regarding condom use.

Urban to rural routes of HIV infection spread in Ethiopia

A descriptive survey to identify routes of spread of HIV infection from urban to rural populations was carried out in a rural south-central Ethiopian district. High risk practices for HIV infection and transmission were first documented among rural residing former soldiers, merchants and students. Extramarital intercourse during the previous 3 months was reported by 45-50% of these subgroups. In 25-37%, intercourse with an urban commercial sex worker (CSW) was reported and condom use varied from 10 to 30% among subgroups. The perceived risk for AIDS was low and changes in risk behaviours were minimal. Next, 502 rural males farmers were surveyed. An extramarital sexual contact in the past 3 months was reported by 13.5%, with 7% reporting their most recent contact with an urban CSW. Only 6% of farmers reported using condoms. Awareness of AIDS was reported by 59% and, of these, only 28% perceived they were vulnerable. In this study increased knowledge was associated with more frequent high risk sexual practices. It is concluded that the spread of AIDS into rural communities is occurring as a result of the high frequency of high risk sexual behaviours in specific rural residing subgroups which frequently travel into urban communities in combination with a low background prevalence of high risk practices among the general male farmer population.

The evaluation of surveys of sexual behaviour: a study of couples in rural Senegal

The reliability of self-reported answers about sexual behaviour is assessed by means of a survey of couples in rural Senegal, Africa, carried out in 1992. A total of 51 married couples were followed weekly over a five-week period. Reports for a recall period of seven days are reliable: dates of sexual acts differed by no more than a day in 73 per cent of cases. Reports over longer periods are less reliable. Retrospective recall of coital frequency for a four-week period yields much higher estimates than those obtained with a seven-day recall, particularly for men.

The epidemiology of AIDS in the Vellore region, southern India

OBJECTIVE

To describe the epidemiology of patients with AIDS in Vellore region, Southern India.

DESIGN AND METHODS

Sixty-one patients with AIDS were diagnosed and treated between July 1987 and June 1992. Information on their demographic characteristics and probable modes of acquiring HIV infection was collected at interviews with them and their spouses.

RESULTS

There was a progressive increase in the number of patients seen over the 5 years. The mean ages of the 51 men and the 10 women were 33 and 29 years, respectively. Of the 44 patients from our district (population, 5 million), 28 were from Vellore town and 10 from rural areas. Forty-seven (92%) men had frequently used prostitutes. Of the women, four were prostitutes, one had had multiple sex partners and five had not had extramarital sexual contact. One man and one woman had no other risk factor except blood transfusion. Thirty-one (51%) patients had died by August 1992.

CONCLUSION

The AIDS epidemic in this region is in its early ascending phase, with a doubling time of approximately 1 year. Most men with AIDS were infected by heterosexual contact with prostitutes, while some women were prostitutes themselves. Together with the male-to-female ratio of 5:1, these results suggest that the male population at risk has sex with a much smaller population of female prostitutes, constituting the major chain of transmission. HIV infection is occurring in both urban and rural populations.

Sexual networking in provincial Thailand

Thailand is currently experiencing a major HIV epidemic, spread primarily through heterosexual contact. Patronage of prostitutes is relatively common. In-depth, open-ended interviews were conducted in a Central Thai province with a purposive sample of 181 urban men who had had sexual relations with at least two different women during the prior year. Additional qualitative information is provided by interviews with 50 women. The most common network pattern for men was a combination of commercial and noncommercial sexual relationships. Men reported that they commonly used condoms when they engaged in sex with prostitutes, but condom use was lowest for men who were the most frequent patrons. In noncommercial, nonmarital relationships, men screen partners for risk rather than practice safe sex, and condom use is generally low. Persons involved in noncommercial sexual networks are largely unaware that their partner may link them to a larger network of sexual contacts and associated risks of HIV infection. Men who have both commercial and noncommercial sexual partners can be found throughout the social strata. A program that focuses only on the closed commercial sex network will address only partially the real risk situations.

Sexually-transmitted disease risk in a Micronesian atoll population

The potential health threat of AIDS to the native island-based populations in the Pacific is now widely appreciated by those working in the public-health sector throughout the region. Although several countries in the region are yet to identify any cases of AIDS or HIV seropositivity, there is reason to suspect that heterosexual contact may emerge as a predominant mode of spread of HIV infection into native Pacific island populations. Sexual networks and their relationship to potentially 'risky behaviours' are described for a single native Micronesian atoll community on the basis of ethnographic observation and interviewing. This description is combined with the investigation of historic-demographic dimensions of the epidemiology of sexually-transmitted diseases in the same population to draw some conclusions about the opportunities for HIV transmission and acquisition among the sexually-active portions of this community. Although sexually-transmitted diseases have not had an appreciable epidemiological or demographic impact on the population in the past, the sexual networks within the community and beyond provide ample opportunity for the introduction and spread of sexually transmitted diseases, including HIV and its sequel AIDS.

Human immunodeficiency virus and migrant labor in South Africa

The authors investigate the impact of the migrant labor system on heterosexual relationships on South African mines and assess the implications for the future transmission of human immunodeficiency virus (HIV) infection. The migrant labor system has created a market for prostitution in mining towns and geographic networks of relationships within and between urban and rural communities. A section of the migrant workforce and a group of women dependent on prostitution for economic support appear especially vulnerable to contracting HIV infection since they are involved in multiple sexual encounters with different, changing partners, usually without condom protection. Furthermore, sexually transmitted disease morbidity is extensive in the general and mineworker populations. Historically, migration facilitated the transmission of sexually transmitted diseases and may act similarly for HIV. Problems of combating the HIV epidemic in South Africa are discussed.

More than mothers and whores: redefining the AIDS prevention needs of women

Women are increasingly at risk for AIDS. At the root of this risk is women's relative lack of control over their bodies and their lives. Those women with least control, generally poor women of color, are at greatest risk in both developed and developing countries. To date, AIDS prevention programs have ignored most women, focusing almost exclusively on women in the sex industry and, more recently, prenatal women. We urgently need prevention programs for women that view women as more than "mothers and whores" and recognize that AIDS poses a real risk to many of us; programs that are sensitive to the complex realities of women's lives and offer realistic alternatives that will allow women to protect themselves from HIV infection.

Heterosexual transmission of HIV-1 among employees and their spouses at two large businesses in Zaire

To better understand the reasons why up to 80% of all HIV-1 infections in Zaire, but less than 5% in North America and Europe, are acquired through heterosexual transmission, and to assess the impact of HIV-1 infection on a large urban African workforce, we enrolled 7068 male employees, 416 female employees and 4548 female spouses of employees at two large Kinshasa businesses (a textile factory and a commercial bank) in a prospective study of HIV-1 infection. The HIV-1 seroprevalence rate was higher in male employees (5.8%) and their spouses (5.7%) at the bank than among male employees (2.8%) and their spouses (3.3%) at the textile factory. At both businesses HIV-1 seroprevalence was higher among employees in managerial positions (5.0%) than among workers in lower-level positions (3.0%; P less than 0.0001). In a multivariate analysis of male employees, receipt of a transfusion, a history of genital ulcer disease, working at the bank, urethritis, or being divorced or separated were independently associated with HIV-1 infection. During 1987 and 1988, AIDS was the most common cause of death among recently employed workers, accounting for 20 and 24% of all deaths at the textile factory and the commercial bank, respectively. The HIV-1 seroprevalence rate was higher among female workers (7.7%) than among the spouses of male workers (3.9%; P = 0.001). In multivariate analysis of the wives of workers, having an HIV-1-seropositive spouse, receipt of a blood transfusion, or a history of genital ulcer disease were independently associated with HIV-1 infection.(ABSTRACT TRUNCATED AT 250 WORDS)