The HIV/AIDS epidemic has been spreading in China for more than two decades. Currently, there are approximately 650 000 people living with HIV in China . Although the epidemic remains largely confined to high-risk groups, it has begun spreading from the originally infected groups – injection drug users (IDU) and former commercial plasma donors – to sexually active heterosexuals and homosexuals [1,2]. Rural-to-urban migration may play a crucial role in shifting the HIV epidemic by broadening social and sexual mixing [3–9]. Young, rural-to-urban male migrants have been identified as the ‘tipping point’ for the AIDS epidemic in China . According to the Chinese National Bureau of Statistics , in 2000 there were 121 million internal migrants in China, 73% of whom were from rural villages. Internal migration has heightened concern over HIV prevention efforts, as various studies have found that relative to non-migrants, migrants are at greater risk of contracting and transmitting HIV [3,4,8,9]. In addition, migrants' perceived HIV risk, knowledge of HIV, and rates of condom use are low and they face barriers to accessing education and healthcare . It is therefore not surprising that HIV prevalence among rural-to-urban migrants is relatively high .
A subgroup of migrant workers at particular risk of HIV are known as ‘money boys’; men who have sex with men for money. There are an estimated 380 000 money boys in China [14,15], but very little research has been done on this group, and only one English-language publication is in print . Clearly, further investigation of this subgroup is needed . Moreover, current understanding of Chinese men who have sex with men (MSM) in general is limited, with few studies published in English [18–25]. Sentinel surveillance in 2006 indicated an HIV prevalence among this group of 1–4% . In 2006, the government classified MSM as a high-risk group .
In 2003, Chng and colleagues proposed a heuristic conceptual model for studying migratory health. This tripartite ‘Impact Domain Model’ postulates that risk behaviours (e.g., HIV-related risks) engaged in by transient or non-native individuals are often shaped or regulated by three factors: home environment; migration experience; and current environment . Using this model, we conducted a cross-sectional study in Shanghai, China to: (1) estimate the profile of HIV-related risk behaviours and testing activities; and (2) elucidate factors for preventing HIV among two types of male migrants – money boys and general male migrants (GMM).
This study was approved by the institutional review boards of Georgetown and Fudan Universities.
Study population and sampling methods
To be eligible for the study, participants must have been: (1) aged 18 or above; (2) from somewhere other than Shanghai; and (3) able to give verbal and written consent in Mandarin. Money boy participants also needed to: (1) self-report having ever had sex with men; and (2) self-identify as an money boy.
Money boys were recruited with assistance from a local non-governmental organization (NGO) working with MSM, and through a variation of snowball sampling methodology modelled after respondent-driven sampling (RDS). The local NGO recruited 53 participants and another 186 were recruited through RDS, bringing the total to 239. Three money boys were invited to act as seeds for the RDS recruitment; 131 money boys were recruited through the first seed, 42 through the second, and 13 through the third. GMM were recruited from venues that they were known to frequent. Based on findings from a pilot qualitative study , we recruited GMM primarily from construction sites, barbershops or hair salons, and other community-based venues.
The nature and purpose of the study was explained to each participant after which they were asked to sign their consent to participate and complete the questionnaire. A copy of the signed consent form was given to the participant. For GMM, 100 Chinese Yuan (US$12.50) was paid as an incentive, and for money boys, 300 Chinese Yuan (US$37.50) was paid. The self-administered questionnaire collected information on demographic characteristics, migration experiences, HIV/AIDS knowledge, attitudes, beliefs and behaviours (KABB), substance use/misuse, sexual risk behaviours, HIV and sexually transmitted disease (STD) testing, access to other healthcare services, and depression. The survey took approximately 30 to 75 minutes to complete. A research assistant was onsite to answer any questions related to the survey.
Chi-square analyses were used to test for associations between type of male migrant (money boys vs. GMM) and demographic characteristics as well as migration experiences and four domains of health risks: (1) HIV KABB, (2) unprotected sex with a casual partner, (3) alcohol use before sex, and (4) HIV/STD testing behaviours. Multivariate logistic regression analyses were conducted, adjusting for demographic and migration characteristics. Correlations among demographic and migration characteristics were assessed before the multivariate regression model was constructed in order to avoid multicolinearity.
Socio-demographic characteristics of study participants
Study participants included 239 money boys and 100 GMM. One hundred and ninety-two (80.7%) money boys self-identified as homosexuals. Money boys were younger than GMM (25.2 vs. 29.9 years; P < 0.001) and were more likely to be better educated, unmarried, and earn a higher income (Table 1).
Three impact domains shaping migrants' behaviours
Home environment (impact domain 1)
The employment status of money boys and GMM was significantly different prior to their first migration. The money boys were more likely to have been employed or waiting for employment, while 22% of GMM (vs. 10.5% of money boys) were farmers (Table 1). The opportunity to make more money was the most cited reason to migrate for both money boys (58.6%) and GMM (50%). Other reasons for migrating included a desire to see the outside world, the opportunity to gain more personal freedom, and limited employment opportunities in their hometowns.
Migration experience (impact domain 2)
The majority of participants had migrated to other cities before arriving in Shanghai, although the proportion was significantly higher among money boys (75 vs. 63%; P < 0.05). The proportion of those who migrated more than ten years ago was significantly higher among GMM (Table 1).
New environment (impact domain 3)
Sixty-four percent of the GMM had received job offers before migrating to Shanghai, meaning that most GMM knew what they would be doing and where they would be living in Shanghai. In contrast, only 22.2% of money boys had arranged work before moving, suggesting their migration was less well-planned. GMM also had lived in Shanghai much longer than money boys (Table 1).
The living situations were also significantly different between money boys and GMM, with approximately 46% of money boys and 12% of GMM living alone. However, participants from both groups rarely lived with a spouse, sex partner or family members.
A greater proportion of money boys were unsatisfied with their current working and living situations compared with GMM (22.6 vs. 10.0%; P < 0.01). Money boys also experienced more stress than GMM; however, participants from both groups had experienced discrimination as a result of their migrant status. Both money boys and GMM were most likely to connect with friends, colleagues, and people from the same hometown (i.e., Lao Xiang in Chinese) and were rarely in contact with local government officials and acquaintances. Money boys were less likely than GMM to connect with family members.
HIV/AIDS-related knowledge, attitudes, beliefs and behaviours
Both money boys and GMM had substantial misconceptions regarding HIV transmission, prevention, diagnosis and treatment, although the money boys seemed to be slightly more knowledgeable about HIV/AIDS than GMM (data not shown). The most serious misconceptions concerned the use of antibiotics and condoms for preventing HIV transmission. Only 37.7% of money boys and 30% of GMM knew that regular use of antibiotics could not prevent HIV infection. Only 62.3% of money boys and 37% of GMM knew that condom use could prevent HIV transmission.
Moreover, both money boys and GMM held very negative attitudes towards HIV-infected individuals and their family members. Only 21% of money boys and 32% of GMM would be willing to work with an HIV-infected individual and only about 40% of study participants would be willing to work with an uninfected colleague who had an HIV-infected family member.
Unprotected sex with a casual partner and alcohol use before sex
Comparisons between money boys and general male migrants
Given the nature of their employment as male sex workers (MSW), all money boys had sexual experience, compared with 83 (83%) GMM (Table 2). As shown in Table 2, money boys were much more sexually active than GMM (P = 0.006); were more likely to have had anal sex with their main sex partners (89.1 vs. 1%, P < 0.001); had a greater number of sexual partners in the past year (86.6 vs. 3% had >5 partners, P < 0.001); engaged in more oral sex (92 vs. 9%, P < 0.001); and were more likely to have casual sex or one-night stands (82 vs. 34%, P < 0.001). Roughly 34% of participants from both groups reported having unprotected sex while under the influence of alcohol (P = 0.347).
Commercial sex among general male migrants
Fourteen (17%) out of 83 sexually active GMM had ever purchased sex with a female sex worker and 53.8% of these GMM did not use condoms with female sex workers. No significant differences concerning commercial sex and condom use were observed between GMM of different occupations (data not shown).
Sex with other men among money boys
For money boys, the mean age at first sexual experience with a man was 20.3 years (range: 13–29). This was not significantly different between those self-identifying as homosexual and those identifying as heterosexual (P = 0.7574). Most money boys had had sex with another man in the past 30 days (85%) and almost all had had sex with a man in the past 12 months (98.8%) (Table 3). A substantial proportion of the money boys did not use condoms while providing sexual services to their male clients. The monetary amount charged for each time of service varied from fewer than 100 Chinese Yuan (US$12.50) to more than 500 Chinese Yuan (US$62.50).
Eleven money boys reported having been raped by another man before reaching the age of 10 (Table 3). Forty-six (19.2%) of money boys had experienced some sexual violence, primarily at the hands of their male clients.
More than half (56.5%) of the money boys and only one GMM had been tested for HIV. The self-reported HIV prevalence among money boys was 3%. However, 26% of those who had been tested did not know the result. The one GMM who had been tested self-reported to be HIV-negative. Thirty percent of money boys had been tested for an STD other than HIV, and 29% had tested positive. Most attended a certified clinic (e.g. a certified hospital or an STD clinic at the local CDC) for STD treatment. Only one GMM had been tested for an STD other than HIV, and he did not know the results of the test.
Only half of the money boys and a quarter of the GMM were aware that free HIV counselling and testing are available in Shanghai and in many other places in China. Numerous money boys and GMM did not know where to go for HIV testing.
Multivariate analyses indicated that being under age 20 [odds ratio (OR): 6.4, 95% confidence interval (CI): 2.1–19.2] and experiencing unemployment in the hometown (OR: 1.7, 95% CI: 1.3–2.1) were significant predictors of lower HIV knowledge, whereas higher education level (OR: 0.6, 95% CI: 0.4–0.8) had a protective effect against lower HIV knowledge. Lifetime sex with a casual partner was used as a proxy for sexual risk. Higher education (OR: 1.7, 95% CI: 0.4–0.9) and migrant type (i.e. being a money boy) (OR: 3.3, 95% CI: 0.7–6.7) were predictors for having ever had casual sex, while those who were married were less likely to have engaged in casual sex (OR: 0.4, 95% CI 0.2–0.9). Unemployment (OR: 1.3, 95% CI: 1–1.6), higher education (OR: 1.8, 95% CI: 1.2–2.7), and migrant type (being a money boy) (OR: 4.5, 95% CI: 2.2–8.9) were all found to be significant predictors for having sex under the influence of alcohol. Working as a money boy was found to be the only significant predictor for taking an HIV test (OR: 58.8, 95% CI: 12.9–267.8). Unemployment in the hometown (OR: 1.5, 95% CI: 1.1–2) and migrant type (being a money boy) (OR: 13.9, 95% CI 3.6–53.6) were significant predictors for taking an STD test. In summary, after adjusting for multiple variables, migrant type was the best predictor for HIV testing, STD testing, casual sex and alcohol consumption before sex.
The findings from the present quantitative study are consistent with those of an earlier qualitative study carried out among the same populations . Compared with GMM, money boys were much younger, better educated, and more likely to be single and living alone. The GMM tended to remain in the same city for as long as possible, whereas the money boys tended to move more frequently between cities. Given that money boys experienced higher levels of stress and were less satisfied with their present situation, it is possible that their high mobility exacerbated their stress.
A number of studies on migrants in China have demonstrated that awareness of HIV risks, HIV/AIDS-related knowledge, and rates of condom use are very low [3,4,8,9]. In the present study, both the money boys and GMM had substantial misconceptions about HIV/AIDS. As sex workers, the money boys engaged in various sexual risks. Some also suffered sexual violence from their clients. Clearly, health education and intervention programmes on HIV/AIDS in urban areas must include migrants – especially money boys – who are very likely to endure social and linguistic barriers to accessing health services.
Our finding that only 21% of the money boys and 32% of the GMM were willing to work with an HIV-infected colleague strongly suggests an urgent need to initiate health education programs among both populations, in order to reduce discrimination towards people living with HIV/AIDS.
In the present study, 19.3% of money boys did not identify as homosexuals, and had sex with other men solely for economic survival. Thus, it would not be surprising to find that these people may also seek to have sex with women. This sexual triangle could create a path for the transmission of HIV or other STD from money boys to females and the general population.
More than half of the money boy participants had been tested for HIV, compared with only one of the GMM. Given that both the money boys and GMM were actively engaging in risk behaviours and that HIV testing is now subsidised by the Chinese government, it is necessary to promote greater awareness of HIV risks, counselling, and testing among GMM and money boys.
The money boys also received more testing for other STD and reported more STD than the GMM. However, previous studies on migrant workers in China have indicated that many male migrants will contract at least one STD, although they may not exhibit any symptoms [29,30]. Since individuals with certain STD are generally more susceptible to HIV infection, we encourage the promotion of STD awareness, testing, and treatment among GMM as well as money boys.
One limitation of this study is that only 100 GMM were recruited through convenience sampling. Thus, this sample may not be representative of Shanghai's male migrant population. Another limitation is that we were unable to compare money boys to a sample of MSM who do not exchange sex for money. However, the authors recently received additional funding to perform more extensive research on the money boys population in Shanghai. Thus, we anticipate learning more about their reasons for migrating to Shanghai and becoming involved in prostitution. We also expect to gain more intimate knowledge about the lives and experiences of the money boys.
In conclusion, this study suggests an urgent need to implement comprehensive HIV/AIDS education and intervention programs to target GMM, money boys, and their clients. Future research projects should be designed to further our understanding of risk behaviours and the HIV epidemic among money boys in China.
Chinese and English versions of the questionnaire are available from the first or second author upon request.
Sponsorship: The study was supported by a United States National Institutes of Health National Institute on Drug Abuse grant (R01DA15623-04S1) awarded to the second author.
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