HIV/AIDS-related knowledge, attitudes, and practices
among the general population in China: Implications for
Deborah Holtzman,1 Shengli Chen,2
Shikun Zhang,2 Jason Hsia,1
Richard Rubinson,3 Feng Yun Bao,2
Lixia Mo,2 and David V. McQueen1
Vol. 3, No. 1, January 2003
hina is the
world’s most populous country, and yet relatively little is
known about the acquired immunodeficiency syndrome (AIDS)
epidemic confronting that nation. The number of cases of human
immunodeficiency virus (HIV)/AIDS in China is not known with
any assurance, and few data are available about the level of
HIV-related knowledge among the population. We analyzed data
from a government-sponsored survey conducted in 2000 in seven
Chinese counties. Our findings indicate that the general
population aged between 15 and 49 years is very often
uninformed about basic issues. The results suggest an
immediate and urgent call for action in the form of widespread
HIV prevention measures.
acquired immunodeficiency syndrome (AIDS) epidemic firmly
entrenched in many countries throughout the world, there is
still much to understand about the epidemiology of the disease
in countries such as China, where AIDS is either a recent
phenomenon or not too much record has been recorded. According
to the Chinese Ministry of Health, from 1985 to the end of
2001, a total of 30,736 cases of AIDS or human
immunodeficiency virus (HIV) infection (confirmed by testing)
had been identified .
Of these cases, 1594 were identified with full-blown AIDS, 684
of whom were reported to have died. These figures contrast
sharply with the estimation that more than 850,000 individuals
would be infected with HIV by the end of 2001 . This number still seems small when
viewed against a total population of 1.276 billion.
Regardless, the data indicate that HIV/AIDS has a firm
foothold in China. Moreover, the Ministry of Health expects up
to 10 million infections by 2010 if effective prevention
measures are not immediately implemented.
To gauge the understanding of HIV/AIDS among the general
population in China, the Information, Education and
Communication Department of the State Family Planning
Commission conducted a survey to assess HIV-related knowledge,
attitudes, perceptions, and selected reproductive practices of
persons aged between 15 and 49 years in seven counties.
unaware of any earlier studies of HIV/AIDS-related knowledge,
attitudes, and practices conducted among the general
population of China. Selected populations have been studied,
however, including Dai ethnic villagers in Yunnan province, health care workers, sexually transmitted diseases (STDs)
young males in Southwest China,
sex workers, and adolescents.
1994 survey of Dai villagers, Liao and coworkers found that
only 18% of respondents had heard of AIDS, only 25% had heard
of STDs, and only 28% had heard of condoms. Among those who had heard of AIDS, STDs,
and condoms, there was still little specific knowledge of
disease transmission. In a survey of health professionals in
11 areas in China, 67.6% of health care workers correctly
answered all three questions about HIV transmission routes and
about half (49.5%) knew that blood is the most efficient route
Three percent knew about the need for universal precautions.
Among patients attending an STDs clinic in Jinan, Shandong
over a 6-month period in 1998, researchers found that
respondents generally had little HIV knowledge, engaged in
risky sexual behavior, and were unlikely to always use
survey including young men from villages in Longchuan, Yunnan,
found that over half (55%) of respondents incorrectly answered
all questions about transmission and prevention.
Risky behavior (injection drug use, sharing injection
equipment, and lack of condom use) were also common. Knowledge
about transmission of STD, including HIV, was also examined in
a study of sex workers in Guangzhou Municipality. Among the women who were interviewed,
counseled, and tested for STDs/HIV during 1998 and 1999,
knowledge about STDs/HIV transmission and the use of condoms
was low. Finally, in a study of students attending secondary
schools in Hong Kong, 13.9% rated themselves as having much
HIV/AIDS knowledge (7).
Most of the students rarely or never discussed HIV/AIDS with
their family (85%), teachers (80%), or friends (60%).
Television was their primary source of information about
studies paint a discouraging picture, and suggest that in
general much of the Chinese population know little about
HIV/AIDS as well as how to prevent its spread. The information
about the epidemiology of HIV infection in China must be added
to this picture, although here the research is also limited.
Yu and coworkers described the situation nationally for the
period from 1985 to 1994 with data obtained from the Chinese
Ministry of Public Health. At the end of 1994, only 1774 HIV
positive or AIDS cases had been identified. Similar to the
situation in the United States in the 1980s, most of the cases
were among males under 39 years of age. Unlike the United
States, however, most were reported drug users. Over
two-thirds (68.1%) were farmers. More than 80% of cases were
from Yunnan Province (and within Yunnan among Dai ethnic
minorities), although there was evidence that the virus was
beginning to emerge in urban areas (Beijing, Shanghai,
Guangdong, and Fujian). By 1996, 30 out of 31 provinces,
municipalities, and autonomous regions had reported cases of
of studies have examined behaviors related to the risk of HIV
infection among selected populations in China. In 1997 and
1998, Zhang and colleagues surveyed 426 men who had sex with
Risky sex was common: 93.4% engaged in orogenital intercourse,
63.6% in anogenital intercourse, 15.5% always in insertive
anal intercourse, and 7.8% always in receptive anal
intercourse. A median of 9 cumulative sex partners was
reported and nearly two thirds never used condoms. Among the
302 men with information on STDs, 25.5% reported that they had
contracted an STD. Almost half (48.4%) reported that they had
engaged in sexual intercourse with women and one-third that
they had been married. These findings suggest a very efficient
way for HIV spreading, both to men and women in mainland
Thomas interviewed 1254 Hong Kong men aged between 18-60 years
in 1997 upon their return from mainland China (11).
Almost one third (32.3%) reported that they had sexual
intercourse with one or more commercial sex workers (CSWs) in
the previous 6 months while traveling in China, and 11.3%
reported the same behavior during their most recent trip.
Percentages were higher for younger and less educated men.
Among those who reported sexual intercourse, about one-third
not always used condoms, and almost 8% of all respondents said
that they would not use a condom with a CSW in mainland China.
Those who would not or did not use condoms with CSWs were less
likely to use condoms with their wives or girlfriends. In
addition, 20.1% of respondents reported that they had an STD.
This combination of behaviors and STDs suggests a scenario for
an increasing incidence of HIV infection in Hong Kong.
study of patients who visited an STD clinic in Jinan, Wang and
colleagues found that most participants had multiple partners
in the previous 12 months (87.1% of men; 54.0% of women), with
a mean of 6.2 partners for men and 7.2 for women. Over two-thirds of men reported
exchanging money for sex and 24% of women reported exchanging
sex for money. None of the women and less than 5% of the men
always used condoms with their spouses, boyfriend/girlfriend,
or others, and over two-thirds of the men never used condoms
with someone other than their spouse or girlfriend/boyfriend.
additional reports examined the prevalence (and in one case,
the incidence) of HIV infection among other selected
populations. A study of plasma/blood donors in rural eastern
China found that 1043 (69%) of 1517 persons who were
interviewed and tested for HIV had previously donated plasma.
Overall, the prevalence of HIV infection was 8.9%, and it was
significantly higher (12.5%) among plasma donors than among
those who denied donating blood (1.3%). The prevalence of
secondary transmission (among the donor’s non-donor spouses)
was 2.1%. HIV infection was not associated with a recent
history of invasive medical care, a history of drug use, or a
history of multiple sex partners.
study of 318 heroin users in Pingxiang City (Guangxi Province)
who were tested for HIV infection, Lai and coworkers found a
prevalence of 15.4% at baseline. After a median follow-up of 8.1 months,
the incidence of HIV was 2.38 per 100 person-years. During the
second follow-up (median of 8.3 months) of 130 users,
incidence increased to 6.86 per 100 person-years. The authors
documented substantial needle sharing and a high incidence of
hepatitis C Virus (Hepatitis C Virus) infection among respondents, both of
which may facilitate the transmission of HIV. Finally, in the
study by van den Hoek and colleagues of sex workers in
Guangzhou Municipality, the prevalence of HIV infection was
low (1.4%), but the prevalence of other STDs was high. Only 30% of sex workers reported that
they always used condoms with their clients.
these results may not directly apply to the general
population, they are certainly evidence of the presence of HIV
infection in China, of a possibly increasing problem, and the
potential for greater spread. It is therefore important to
begin examining the level of HIV/AIDS knowledge among the
general population so education and intervention can be
appropriately targeted for this group. The purpose of this
paper is to describe the HIV-related knowledge, attitudes, and
other factors from our survey of Chinese residents in the
seven counties. We expected to find a relatively low level of
knowledge among the general population and a variation
according to sociodemographic patterns.
before the Chinese government acknowledged in August 2001 that
the country was facing a serious AIDS problem (1),
the situation had reached a critical level. By 1996, all but
one province had been touched by the epidemic.
From 2000 to 2001, the number of new cases of HIV/AIDS
increased 58% and the number of people estimated to be
infected with HIV increased 30%. The potential for further
spread is substantial and pathways to the general population
of knowledge on HIV/AIDS transmission and prevention
to surveys of more selected populations, ours indicates an overall lack of
knowledge about HIV/AIDS transmission and prevention among the
general population of individuals between 15 and 49 years old
in China. Although the majority of respondents had heard of
AIDS and said that they knew that it can be transmitted and
prevented, most did not know more specific information, such
as the cause of the disease, how to detect it, the modes of
transmission, or how to prevent it. Not surprisingly, the more
educated and economically advantaged groups were better
informed, but even within these groups, the level of knowledge
about HIV/AIDS was only moderate.
overall lack of knowledge about HIV suggests that the general
public lacks a sense of risk about transmission and an
awareness of self protection. Close to 17% of respondents had
never heard of HIV. Of those who had, almost 6% said that they
would do nothing if they suspected that they were infected
with HIV and, surprisingly, close to 90% said that they would
not avoid sexual intercourse. There was also a general
reluctance among respondents to talk to anyone about AIDS.
Indeed, about 40% said that they would avoid contact with HIV
positive individuals and most respondents indicated that they
would have little concern or sympathy for acquaintances who
were infected. These attitudes only serve to promote stigma
and discrimination and certainly increase the problems of
those living with HIV or AIDS.
findings are reminiscent of a 1996 survey of college students
from one university in China. Most students said that they would feel
sympathy for someone with AIDS, at the same time, they felt
that those who had the disease should be separated from others
(i.e., quarantined) and that persons with AIDS have the
responsibility to be considerate of others by isolating
themselves. Moreover, several students said that they would be
less sympathetic towards someone with AIDS if the disease was
contracted through homosexual activity, injection drug use, or
promiscuous heterosexual sex, rather than if the person
acquired the infection as a child or hemophiliac.
of an effort to educate the general population about AIDS, the
survey findings suggest a major focus on the benefits of
condom use. Respondents were asked about current contraceptive
practices and whether they had ever used condoms. Only 5.5% of
respondents said that they were currently using condoms for
contraception and just over one quarter (28.4%) reported that
they or their spouses had ever used condoms. However, we did
find that experience with condoms was related to being more
informed. Those who were currently using condoms and those who
had ever used condoms were more likely to know that using
condoms correctly can prevent HIV/AIDS. The reverse was also
true. Those who were more knowledgeable about condoms were
more likely to have used condoms. Increasing knowledge about
condoms may help to increase condom usage which in turn, may
help to prevent HIV transmission.
were further queried about their sources of HIV/AIDS
information, that is, where they obtained current information
and where they preferred to obtain information. In both
instances, the majority obtained and had a preference for
obtaining their HIV/AIDS information from TV, followed by
books or newspapers and the radio. Only a small percent of
respondents obtained or preferred to obtain their information
from medical experts or family planning agencies. However,
those who were more knowledgeable about HIV/AIDS were more
likely to obtain their information from family planning
agencies or medical experts, rather than from media sources.
Increasing education about AIDS may help to ensure that the
most informative avenues for information are utilized.
the relatively low levels of knowledge about HIV/AIDS, almost
84% of respondents said that it was necessary to teach
HIV/AIDS prevention education in school and that middle school
was the appropriate time for this type of instruction to be
provided. School-based prevention education would certainly be
one avenue to inform the general population of adolescents,
particularly if they are reached before they become sexually
apparently conflicting finding (low level of HIV knowledge and
strong support for HIV/AIDS education in school) is difficult
to explain, although social desirability may contribute to the finding that a
majority of respondents supported HIV/AIDS education in
school. Also conflicting was the fact that over two-thirds
(67.5%) of respondents recognized that AIDS could be
transmitted through sexual intercourse, yet almost 90% said
that they would not avoid sexual intercourse when asked what
they would do if they suspected that they were infected. Again
these responses are difficult to reconcile, but given the
overall lack of knowledge about HIV/AIDS, it seems plausible
that the relatively high prevalence of those who knew this
particular route of transmission (sexual intercourse) may be
less than reliable.
are other limitations to our data that should be recognized.
Although households were sampled to obtain at least 1000
respondents in each county, we have no information on those
who refused to participate or those who could not be contacted
at home. Therefore, we do not know whether these individuals
systematically differed from those who participated, in which
case our sample would not be representative. In addition,
because our data were self-reported, we have to allow for both
under and over reporting. Finally, since this is the first
major HIV-related survey of the general population, additional
work will need to be conducted to ensure the validity of these
data. However, the relatively consistent pattern of our
findings, coupled with the magnitude of many of our estimates
(even with over reporting taken into account), suggests that
there is little specific knowledge about HIV/AIDS among the
general Chinese population.
this lack of knowledge must be addressed, especially as the
AIDS problem intensifies throughout the country. It is
important that preferred sources of HIV/AIDS information are
taken into account and examined closely. The national
information and education campaigns should use these findings
to correctly inform the public and potentially prevent new
infections. Information about the role of condoms in
preventing infection and easy access to condoms should be
included in these educational efforts. The apparent public
support for school-based education should also be considered
in any national or provincial effort. In addition, negative
attitudes towards persons with AIDS must be taken into account
and policies should be implemented to prevent stigma and
discrimination. The substantial and growing HIV/AIDS problem
will not only affect China, but the rest of the world as well
and it is in the interest of all to address it quickly and
effectively. National and international cooperation in the
fight against AIDS in China is urgently needed.
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