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HIV-Related Risk Factors Associated with Commercial Sex Among Female Migrants in China HONGMEI YANG, XIAOMING LI, BONITA STANTON, XINGUANG CHEN, and HONGJIE LIU http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1791013 The Carman and Ann Adams Department of Pediatrics, Wayne State University Prevention Research Center, Detroit, Michigan, USA XIAOYI FANG and DANHUA LIN Beijing Normal University Institute of Developmental Psychology, Beijing, China RONG MAO Nanjing University Institute of Mental Health, Nanjing, China Address correspondence to Hongmei Yang, MD, PhD, Prevention Research Center, The Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, 4201 St. Antoine Street, Suite 6D, Detroit, MI 48201, USA. E-mail: hoyan@med.wayne.edu The publisher's final edited version of this article is available at Health Care Women Int. Abstract Data from 633 sexually experienced female migrants were analyzed to examine the sociodemographic and psychosocial factors and human immunodeficiency virus (HIV)-related behaviors associated with involvement in commercial sex. Six percent (40/633) of the participants reported having had sex for money. Compared with women who had not engaged in commercialsex, women who had sold sex were younger, less educated, and more likely to be unmarried. They were more likely to have engaged in HIV-related risk behaviors, such as becoming intoxicated with alcohol and using drugs. Among women who engaged in commercialsex, only 28% of them consistently used condoms during the last three episodes of sexualintercourse. Women who had ever engaged in commercialsex demonstrated greater depressive symptoms than those without such a history (p<.01). Female migrants, especially those engaging in commercial sex, were vulnerable to HIV/sexually transmitted diseases (STDs). Sexualrisk reduction and condom promotion are urgently needed among this population. Further studies are needed to examine the causal relationship between depression and HIV risk behaviors.   The role of commercial sex in the global HIV epidemic has been especially prominent in selected countries in Southeast Asia. Typically, the transmission path has been from drug users to sex workers, from sex workers to clients, and finally from clients to wives and regular sexual partners in the general population (Gangakhedkar et al., 1997; Weniger et al., 1991). To date, such a transmission path has not been widely evident in China. In some provinces with high rates of illicit drug use, however, the HIV prevalence rate among sex workers has been found to be as high as 11% (Settle, 2003). Sex workers in China, like their counterparts in other countries, appear to be especially vulnerable to HIV infection. A high prevalence of STDs and low rates of consistent condom use have been reported among these women (Gil, Wang, Anderson, Lin, & Wu, 1996; UNAIDS, 2003a). In the absence of effective prevention strategies suitable for this population, sex workers may serve as a “bridge population” in the further outbreak of HIV/acquired immune deficiency syndrome (AIDS) in China. Few efforts have been made among this population in community settings to examine their HIV-related behaviors and other risk factors for HIV infection, although recently limited studies have been conducted among sex workers recruited from entertainment establishments (Liao, Schensul, & Wolffers, 2003; Rogers, Liu, Yan, Fung, & Kaufman, 2002; Qu et al., 2002; van den Hoek et al., 2001). Although providing valuable information about HIV risk behaviors and condom use, these studies did not include comparison groups. In addition, most of these studies did not examine psychosocial factors such as depression and peer risk involvement, which have been found to be related to risk behaviors in western nations (Alegria, Vera, Freeman, Robles, Santos, & Rivera, 1994; Perdue, Hagan, Thiede, & Valleroy, 2003; Simpson, Knight, & Ray, 1993). The current study, comparing female migrants who had engaged in commercial sex with female migrants who had not engaged in commercial sex, therefore, was designed to (1) examine the sociodemographic characteristics of female migrants engaging in commercial sex; (2) explore their HIV-related risk behaviors and perceptions; and (3) explore the association between depression and involvement in commercial sex. BACKGROUND In China, the incidence of HIV infection is increasing at an annual rate of more than 30%. Since the first AIDS case was reported in 1985, 62,159 infections had been documented through 2003. It is estimated that the number of actual infected individuals is approximately 840,000 (Yang et al., 2004). Injection drug use is the predominant mode of HIV transmission, followed by commercial blood/plasma collection. Blood/plasma donors were infected through unsafe blood/plasma collection practice, including using contaminated collection instruments (e.g., syringe and needles) and reinjecting contaminated blood cells back into donors during group collection (Wu, Rou, & Detels, 2001). The proportion of persons infected through heterosexual intercourse, however, appears to be increasing, from 5.5% in 1997 to 10.9% in 2002 (UNAIDS, 2003b). In eastern and coastal China where heterosexual transmission is the major mode of HIV transmission, many of the reported HIV infections occurred among high risk groups such as STD patients and commercial sex workers (Zheng, 1999). Commercial sex is illegal in China. If arrested, women engaging in commercial sex are fined or sent to a women’s reeducation center, where they are detained for 3 months to 2 years to undergo correction and rehabilitation. Since the early 1980s when commercial sex reemerged in mainland China after two decades of virtual extinction, however, the sex trade has developed into a widespread industry (Pan, 1999). In 2003, it was estimated that more than 10 million women were engaging in commercial sex (Schafer, 2003). Most sex workers are female migrants who temporarily relocated from poor rural areas to larger urban areas (Gil et al., 1996; Lau, Tsui, Siah, & Zhang, 2002a; van den Hoek et al., 2001). They are young, have received limited formal education, and have inadequate knowledge about HIV/AIDS and reproductive health (Zheng et al., 2001). METHODS Research Sites Two metropolitan cities, Beijing and Nanjing, were selected as our study sites. Beijing, the capital of China with a population of 13.82 million, is located in northeast China. According to 2000 census data, the rural migrant population in Beijing was estimated to be 3 million, including 31% female. Nanjing, the capital city of Jiangsu Province with a population of 5.3 million, is located in the east of China. The rural migrant population in Nanjing was estimated to be 800,000 (Li et al., 2004). Sampling and Data Collection Data in the current study were obtained from a feasibility study of an HIV/STD behavioral prevention intervention among Chinese rural-to-urban migrants in 2002. Eligible participants were defined as those who (1) had previously resided in a rural area; (2) worked in the city without having a permanent city residence; (3) had been in the city for at least 6 months; and (4) were between 18 and 30 years of age. A total of 4,208 migrants (1,699 or 40% female) from Beijing and Nanjing participated in the study. Detailed methods of data collection have been described elsewhere (Li et al., 2004). Briefly, 10 occupational clusters (restaurants, hotels, barbershops/beauty salons, bathhouses/massage parlors, nightclubs/karaoke/dance halls/bars, small retail shops, domestic services, street stalls, construction sites, and factories), which employed more than 90% of the migrants plus currently unemployed migrants in the job markets, served as the sampling frame. Quota sampling of occupational groups was utilized to achieve a representative sample of migrants in the cities so that the number of participants would be proportional to the estimated number of migrants in each occupational cluster. The workplaces (e.g., store, club, office, construction site, street) were used as the sampling units. To prevent oversampling from any single sampling unit, the number of participants recruited from any unit did not exceed 10% of total migrants in the unit or 10 individuals, whichever was greater. After obtaining permission from gatekeepers, employers, or workplace managers, trained interviewers approached eligible migrants at the sampling units. After providing informed consent, participants were asked to complete an anonymous self-administered questionnaire in a separate room at their workplace or a nearby place convenient to participants. The questionnaire, which was pilot tested and revised before the survey, took approximately 45 minutes to complete. Assistance (e.g., reading questions to them) was provided to the small number of respondents with limited literacy skills. Among the 1,699 female migrants in the feasibility study sample, 728 (42.8%) reported having ever had sexual intercourse. Among them, 633 (87%) provided complete data regarding whether they had ever engaged in commercial sex. The sample in the current study consists of the 633 female migrants. MEASURES Involvement in commercial sex. Participants were asked whether they had ever been paid for sex. According to their responses to the question, they were assigned to one of two groups: those who had ever engaged in commercial sex and those who had not. Sociodemographic characteristics. Sociodemographics included demographic characteristics (age, marital status, and educational level), employment condition (workplace, daily working hours, and monthly income), and history of migration (years of being in the city, frequency of changing jobs, and whom staying with in the city). HIV/STD awareness. Participants were asked to assess along a 4-point response (i.e., nothing, a little, some, and a lot) how much they knew about HIV/AIDS. They also were asked to assess how much they knew about STD symptoms on the same 4-point scale. HIV/AIDS knowledge. Participants’ actual HIV/AIDS knowledge was assessed using 11 items covering modes of transmission and clinical symptoms of HIV infection. These items were presented with a true/false or likely/unlikely response choice. A composite score of AIDS knowledge was created by summing the correct responses (possible range 0-11) of the 11 items, with a higher score reflecting a higher level of knowledge about HIV/AIDS. The internal consistency of this scale was 0.73. In addition, knowledge about specific methods to prevent HIV/STD transmission was assessed by six individual items. HIV-related behaviors. Both risky and protective sexual behaviors were assessed, including the number of sexual partners in the last month, whether their sexual partner was having sex with others, number of times using a condom during the last three sexual encounters, and condom discussion with sexual partner. Other HIV-related risk behaviors also were assessed, including having sold blood or plasma for money at least once last year, having been intoxicated with alcohol at least once last month, and having ever used illicit drugs (e.g., heroin, opium, and marijuana). In addition, information on participants’ sexual history was collected including age at first sexual encounter and whether their sexual debut occurred before or after marriage. Vulnerability. Participants were asked to rate their perception of their likelihood of acquiring HIV or an STD infection on a 5-point scale (1 = unlikely, 2 = somewhat likely, 3 = likely, 4 = very likely, and 5 = having already been infected). The last four categories were combined to form one category (i.e., “likely”). Attitudes toward condom use. Participants were asked to indicate whether they agreed with statements regarding efficacy of condom use in HIV/STD prevention (one item), self-efficacy to use condoms (four items), and barriers to use condoms (three items). Each statement has a 4-point response option ranging from “1 = strongly disagree” to “4 = strongly agree.” For the purpose of data analysis in the current study, “strongly disagree” and “disagree” were combined into “disagree”; “agree” and “strongly agree” were combined into “agree.” Perceived peer risk involvement. Perception of peer risk involvement was assessed using four questions. The internal consistency of the questions was 0.86. Participants were asked about how many (1 = none, 2 = few, 3 = some, and 4 = most) of their peers (including those at their home villages) had engaged in a number of HIV/STD risk behaviors, including having had multiple sexual partners, having engaged in commercial sex, and having contracted an STD. A composite score was created by averaging the response to the four questions. Depressive symptoms. Depression was measured using the Center of Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). The 20-item CES-D was introduced into China in the early 1990s (Wang, 1993) and was reexamined and modified by the investigators to assure the accuracy of the translation. The internal consistency was 0.87 for the current study sample. The scale score, which was the sum of responses to these 20 items, ranged from 0 to 60, with higher scores indicating higher frequency of depressive symptoms. DATA ANALYSIS All analyses were conducted with SPSS for Windows, Version 11.5 (SPSS Inc. 2002). Descriptive analyses were conducted to illustrate the proportion and patterns of sociodemographic variables for female migrants who had engaged in commercial sex and those who had not. Chi-square tests were performed to examine differences in distribution of categorical variables, and ANOVA was employed for continuous variables. To explore the association of commercial sex experience with other HIV risk behaviors, perceptions, and depression, an odds ratio of involvement in commercial sex was calculated for each of these risk factors, adjusting for age, educational level, and marital status. RESULTS Sample Characteristics Among the 633 sexually experienced female migrants, 40 (6.3%) reported that they had engaged in commercial sex. The participants’ sociodemographic characteristics are presented overall and by involvement in commercial sex in Table 1. The mean age of the entire sample was 25 years. Nearly half of them had never been married (46.2%) and 59.1% had completed no more than elementary school (9.8%) or junior high school (49.3%). Most of them worked in entertainment establishments (i.e., 46.5% nightclub/bar, barbershop/beauty salon, and bathhouse/massage parlor) or service sectors (i.e., 39.5% restaurant, hotel, retail shop, street stall, and domestic service). Approximately half (59%) worked 10 hours or longer per day. Likewise, about half (52.2%) earned less than 800 RMB (around U.S.$97) per month. Nearly all (91.3%) had been staying in the current city for more than one year, but almost half (48.2%) had changed their jobs at least once per year. TABLE 1 Sociodemographic characteristics of female migrants who were sexually experienced overall and by commercial sex experience Characteristics Overall (n = 633) CS (n = 40) NCS (n = 593) P value Demographics         Age 25.2 ± 3.4 23.9 ± 3.0 25.3 ± 3.5 .013 Ethnicity: Han ethnicity, % 96.3 92.3 96.6 .166 Education: ≤9 grades, % 59.1 71.8 58.3 .097 Never married, % 46.2 76.9 44.1 <.001 Employment condition         Working place in the city, %         Unemployed 3.3 0 3.5 <.05 Entertainment establishments 46.5 70.0 45.0   Service sector 39.5 25.0 40.5   Industrial or constructive sector 5.9 5.0 6.0   Others 4.5 0 5.1   Monthly income ≥800 RMB (or U.S.$97), % 47.8 75.0 46.0 <.001 Daily work hours ≥10 hours, % 59.0 65.0 58.6 .426 History of migration         Staying with whom in the city, %         Alone 10.3 17.5 9.8 .171 Spouse 33.3 7.5 35.0 <.001 Coworker 36.6 35.0 36.7 .867 Village fellow 12.2 32.5 10.8 <.001 Friend 8.2 17.5 7.6 .038 Changing jobs ≥1 per year, % 48.2 65.0 47.1 .028 City resident <1 year, % 8.7 5.0 9.0 .565 CS: women who had ever engaged in commercial sex. NCS: women who had never engaged in commercial sex.   Compared with women who had not engaged in commercial sex, women who engaged in commercial sex were younger (23.9 vs. 25.3 years old, p<.05), less educated (71.8% vs. 58.3% had finished no more than 9 yeas of formal education, p = .10), and more likely to be unmarried (76.9% vs. 44.1% never married, p<.001). A higher proportion worked in entertainment establishments and had higher incomes (75% vs. 46% had monthly incomes of 800 RMB or more, p<.001). They also were more mobile and changed their jobs more frequently (Table 1). HIV-related Behaviors Differences in HIV-related risk behaviors by involvement in commercial sex (yes/no) are presented in Table 2. Compared with women who had never engaged in commercial sex, women engaging in commercial sex were more likely to have engaged in other HIV-related risk behaviors, including both risky sexual behaviors and other risk behaviors. A larger proportion of them reported that their first sexual episode occurred before marriage (87% vs. 57%, p < .05) and when they were younger than 20 years old, the legal marriage age for women in China (74% vs. 36%, p < .001). More of the women (85% vs. 31%, p<.001) reported that either they knew or they were uncertain whether their sexual partners were having sex with others. Women engaging in commercial sex were more likely to report having multiple sexual partners in the last month (43%), compared with 1.7% for their counterparts (p<.001). TABLE 2 Relationship between HIV-related behaviors and involvement in commercial sex Characteristics Total (n = 633) CS (n = 40) NCS (n = 593) Adj. OR (95% CI for OR) P Sexual behaviors & history           Age at first sexual encounter <20y (%) 38.3 74.4 35.9 5.94 (2.45-14.39) <.001 Sex debut occurred before marriage (%) 59.3 87.2 57.4 3.99 (1.13-14.10) .031 Having multiple sex partners, last month (%) 4.2 43.2 1.7 27.84 (10.74-72.16) <.001 Sexual partner has sex with others (%) 34.3 84.6 31.0 9.33 (3.73-23.32) <.001 Consistent condom use, last 3 sexual encounters (%) 16.4 27.5 15.6 1.53 (0.70-3.33) .286 Discussed condom use with sexual partner (%) 55.1 62.5 54.5 1.38 (0.68-2.82) .371 Other risk behaviors           Sold blood or plasma at least once last year (%) 3.7 10.3 3.2 2.20 (0.60-8.04) .233 Got drunk at least once last month (%) 24.8 65.0 22.1 5.37 (2.61-11.06) <.001 Ever used drugs over lifetime (%) 3.0 20.0 1.9 9.12 (3.17-26.26) <.001 CS: women who had ever engaged in commercial sex. NCS: women who had never engaged in commercial sex.   Around 17% of sexually experienced female migrants had always used a condom during the previous three episodes of sexual intercourse and around 55% had discussed condom use with their sexual partners. No significant differences were found between the two groups regarding condom use or communication with their sexual partner regarding condom use. A higher proportion of women engaging in commercial sex, compared with women who had not engaged in commercial sex, reported having been intoxicated with alcohol at least once during the previous month (65% vs. 22%, p<.001). They also were more likely to have a lifetime history of drug use (20% vs. 2%, p<.001), and were more likely to sell their blood or plasma for money (10.3% vs. 3.2%), potentially placing themselves at risk, although the difference was not statistically significant. HIV/STD Awareness and Knowledge Compared with women who had never engaged in commercial sex, a larger proportion of the women who had engaged in commercial sex perceived themselves to be knowledgeable (e.g., knowing a lot) about HIV (12.5% vs. 2.4%, p<.05) and a lower proportion perceived that they knew little/nothing about HIV (40% vs. 53.2%, p<.05). The same tendency was seen for awareness of STD symptoms (data not shown). The mean value of the HIV knowledge score, which ranged from 0 to 11, was significantly higher for women who had engaged in commercial sex (9.14 vs. 7.94, p<.01; see Table 3). TABLE 3 Association of involvement in commercial sex with HIV-related knowledge, perceptions, and depression HIV-related knowledge, perceptions, and depression Total (n = 633) CS (n = 40) NCS (n = 593) Adj. OR (95% CI for OR) P value HIV-related knowledge (Mean ± S.D.) 7.79 ± 2.52 9.14 ± 2.38 7.94 ± 2.37 1.28 (1.08-1.51) .005 Vulnerability to HIV/STD infection (%)           Likely to get HIV infection 28.7 70.0 25.9 6.33 (3.04-13.21) <.001 Likely to get STD infection 34.1 82.5 30.8 8.52 (3.64-19.93) <.001 Barriers to condom use (%)           Few men like to use condoms during sex 67.7 80.0