F. Lau, Joseph T. PhD*; Chen, Rongfeng MD†; Wang, Qingsheng MD*; Diao, Jianxi MD†; Tsui, Hiyi MS*; Yuan, Weixiong MD†
IT IS ESTIMATED THAT 500,000 people in China, including 61,000 women and 4800 children, were living with HIV/AIDS by the end of 1999. 1 The figure may have exceeded 1 million by the end of 2001. 2 The number of reported HIV infections in China rose by 67.4% in the first 6 months of 2001. 2 During 1990 to 1998, the prevalence of sexually transmitted disease (STD) among both females and males in China increased significantly (by 4.2 and 3.8 times, respectively). The incidence of syphilis and gonorrhea had increased by 20 and 2.6 times, respectively, during this period, at an average annual rate of 52.8% and 11.4%. 3
Guangdong Province in Southern China had a population of 86.42 million and a GDP of more than 1000 billion Yuan in 2001 (ranked the first among all provinces in China). It ranked the third in China in the number of reported cases of STD. The figures were on a trend of increase, from 121.46 per 100,000 in 1997 to 128.11 per 100,000 in 2000. 4 In terms of the number of reported HIV cases, the province ranked fourth in the country in 2000. A similar increasing trend has been reported. 5
Guangzhou is the capital city of Guangdong Province, with a population of about 10 million. The incidence of STDs in Guangzhou was 349.90 per 100,000 in 1999, the second highest among all cities in China (next to Shanghai). 6 With the rapid economic development and an opening-up policy, it is expected that these sexual health problems will persist or even become more serious in the future.
STD is related to HIV not only in that the former increases the risk of infection of the latter but also in that both are closely related to unsafe sex. Therefore, better understanding STD patients, one of the groups facing the highest risk of contracting HIV, would help in the prevention of not only STD but also HIV infection. Some STD patients serve as a bridge population in the spread of STD/HIV. For instance, a high prevalence of STD was reported among Hong Kong males who crossed the Hong Kong–China border to purchase sex; these STD patients became a bridge population for the transmission of STD/HIV between Hong Kong and Guangdong. 7–9
A number of studies have shown that STD among female sex workers (FSWs) is prevalent in China; on average, the prevalence is estimated to be higher than 30%. 10 In Guangzhou, the prevalence of STD among FSWs was very high (14% for syphilis, 32% for chlamydia, 8% for gonorrhea, 12.5% for trichomoniasis, and 7.4% for genital warts). 11 A recent study in Shantou, another city in the Guangdong province, showed that the prevalence of STD among FSW exceeded 33%. 12 The prevalence of HIV among FSWs in the Guangdong province is relatively low but it is still considerable. One study showed a figure of 1.4%, which triggers alarm. 12 Condoms are not frequently used by FSWs, and their HIV-related knowledge is poor. 8,13
Information-based intervention programs have been commonly used in HIV/STD prevention campaigns. According to some conceptual models such as the social cognitive theory 14,15 and the KABP framework, 16 knowledge may be associated with reduction in HIV-related risk behaviors. Empirically, results have been mixed. 17–20 Perceived susceptibility of contracting the disease affects whether some risk behaviors will be practiced. 21–24 The statistical significance of such associations was tested in this study. Needs-assessment exercises are required to design effective prevention programs. The study also investigated the likelihood that unprotected sex would be practiced with regular and nonregular sex partners before the patients’ disease was cured. This is an important topic because it determines the speed of possible bridging effects that transmit the virus to other, lower-risk populations.
The study presented the results of a needs-assessment exercise for STD/HIV prevention among STD patients in a metropolitan city (Guangzhou) in southern China. It included several parts. First, the size of the problem, or the level of risk behaviors, was assessed. The second part of the study assessed the level of knowledge and attitudes related to STD, HIV, and condom use, as well as perceived susceptibility to STD and HIV and perceived efficacy of condom use in preventing HIV/AIDS among STD patents. The third part of the study looked into factors predicting the anticipation of condom use with regular or nonregular sex partners before the cure of their STD.
Subjects and Methods
Population and Sampling
Four major hospitals in Guangzhou participated in this study (the Guangdong Provincial Center of Dermatology and Venereal Disease, First Guangzhou People's Hospital, Guangdong Provincial Hospital of Traditional Chinese Medicine, and Second Teaching Hospital of the Guangzhou Medical College). Our impression is that most of the STD patients in Guangzhou go to public hospitals, because the private sector is not well developed. Public hospitals are usually cheaper and exercise better quality control than private clinics. Four clinical specialists in dermatology and venereal disease, one at each of the four hospitals, were responsible for the administration of the study, which was completed in September 2001.
The study population comprised new STD patients who presented at the dermatology and venereal disease clinics of these hospitals. The inclusion criterion, in addition to attendance at one of the four clinics, was presenting with symptoms of a new episode of STD (i.e., not presenting for follow-up). After clinical examinations were conducted, the clinicians recorded the diagnostic information. Those who had an STD clinically diagnosed were invited to join this study. The diagnosis was then confirmed by laboratory tests. After informed consent, the respondents then filled out the self-administered structured questionnaire. For those few whose diagnosis was not confirmed by the laboratory test, the data were removed from analysis. Of the 869 invited, a total of 619 STD patients (440 males and 179 females) participated in this study. The response rate was 71.2%.
The questionnaire consisted of three parts. The first part asked about demographic information (such as sex, age, education, marital status, home province, ethnicity;Table 1). The second part asked about knowledge related to HIV transmission routes (whether HIV could be transmitted via unprotected vaginal sex, unprotected anal sex, needle-sharing, HIV-contaminated blood transfusion, and vertically, from mother to child). Other questions were related to misconceptions about HIV transmission (e.g., whether HIV could be transmitted via hand-shakes;Table 3) and other HIV properties (e.g., whether AIDS is curable;Table 3). In addition, six questions related to STD, three related to condom use (Table 4), and two related to perceived efficacy of condom use for AIDS and STD prevention (Table 4) were asked. Dummy variables according to the number of “appropriate” answers given by the respondents on some of the above-mentioned questions were constructed to assess the level of knowledge about HIV transmission, STDs, and condom use. The third part of the questionnaire included some questions about attitudes and risk behaviors, pertaining to sex with commercial sex workers, condom use, and other factors. Questions on their perceived chance of contracting STD or HIV and the perceived efficacy of condom use for STD or HIV/AIDS prevention were also asked.
The results were tabulated by sex, age group, and education of respondents. Chi-square tests and odds ratios were used to determine significance and to measure the strength of associations. The associations between various risk behaviors and HIV/STD and factors such as condom-related knowledge, perceived efficacy of condom use for HIV/STD prevention, perceived chance of contracting HIV/STD, and history of STD were analyzed with logistic regression models, adjusted for sociodemographic variables. Data analysis was performed with use of SPSS statistical package 10.0 (SPSS, Chicago, IL).
Demographic Characteristics of Respondents
While the male respondents had a more or less symmetrical age distribution, about 70% of the female respondents were in their 20s. Female respondents were also more likely to have attained a lower education level than male respondents (P < 0.001). About 50% of both the male and female respondents were married, and about half of the respondents came from rural areas (P = 0.01). The majority of the respondents, both the male and female, were Han in ethnicity. More female respondents were unemployed than male respondents, and more male than female respondents were professionals or workers (Table 1).
STD History and Diagnoses
About 20.7% and 9.6% of the male and female respondents, respectively, had previously contracted an STD (before this episode of STD). The sex difference was of statistical significance (P < 0.001;Table 1). The distributions of the diagnoses of the current episode of STD (as diagnosed during the interview visit) also differed by sex (Table 1).
Risk Behaviors in the 6 Months Before the Interview
The results showed that 62.0% and 71.4% of the male and female respondents, respectively, had had a regular sex partner in the previous 6 months (P = 0.027), and 71.3% and 28.2% had had one or more nonregular sex partners during the period (P < 0.001). About 30.3% of the male respondents (9.2% of them had visited sex workers more than 5 times) and 2.9% of the female respondents (0.6% of them had visited sex workers more than 5 times) reported that they had had sex with a commercial sex worker in the previous 6 months (P < 0.001); 18.2% and 3.4%, respectively, reported that they had had sex with someone they did not know (a commercial sex worker or other type of sex partner) in the previous 6 months (P < 0.001); and 30.6% versus 22.4% had had sex with a friend or a colleague in the past 6 months (P = 0.043). Very few male respondents (0.9%) reported having abused a substance in the previous 6 months (nil for females; data not tabulated).
Frequency of Condom Use with Regular and Nonregular Sex Partners in the Previous 6 Months
The prevalence of consistent condom users (those who always used condom) for sex with nonregular sex partners, before the current episode of STD infection, was low among both the male and female respondents (17.0% and 6.3%; P < 0.05;Table 2). The prevalence of consistent condom use with regular sex partners was even lower (4.8% and 3.1% for male and female respondents, respectively; P < 0.05). Age and education level had no effect on these prevalence rates (Table 2).
Frequency of Condom Use with Regular and Nonregular Sex Partners Before the Current STD was Cured
Among those who had one or more nonregular sex partners in the previous 6 months, fewer than 30% stated that they probably would not engage in unprotected sex with nonregular sex partners before their STD was cured (Table 2). In fact, 9.4% and 7.4% of the male and female patients believed that they had already engaged in unprotected sex with some nonregular sex partners after having the STD diagnosed. Respondents who were older than 35 years of age were more likely to anticipate not engaging in unprotected sex with nonregular sex partners before the cure of their disease, whereas sex and education level were not significant factors (Table 2).
Conversely, about 90.0% of both male and female respondents stated that it was unlikely they would engage in unprotected sex with their regular sex partners before cure. However, 5.3% of the males and 7.4% of the females believed they had already engaged in unprotected sex with their regular sex partners after diagnosis of the STD (Table 2). Similarly, age and education were not significantly associated with an anticipation of not having unprotected sex before cure (Table 2).
Knowledge about HIV/AIDS
Most male and female respondents (about 85% or more) knew that HIV could be acquired via unprotected vaginal sex, unprotected anal sex, needle-sharing, vertical transmission, and HIV-contaminated blood transfusion. Gender differences were not statistically significant after adjustment for age and education. Education effects in general were associated with a better level of HIV-related knowledge (P < 0.05; data not shown).
Misconceptions about routes of HIV transmission were very common, however, among the respondents (Table 3). Younger respondents and better-educated respondents were less likely to report such misconceptions. Gender differences in this regard were relatively small.
Similarly, respondents did not know about the window-period characteristics of HIV infection, about the asymptomatic nature of HIV/AIDS, or that AIDS is still incurable. Age effects were not significant, but significant education effects were observed (Table 3).
Knowledge Related to STD
Although most of the respondents knew that syphilis is a form of STD, many of them did not know that condyloma acuminata and gonorrhea are STDs (Table 4). A high proportion of the respondents (about 29.7% and 37.3% of males and females) were mistaken that STD patients would be immunized from future infections, that a person could not have two types of STD simultaneously (56.5% and 63.6%), and that an asymptomatic person could not transmit STD to others (about 50% of each group;Table 4). For most items, better education attainment was associated with better knowledge. Age and gender effects were not very apparent (Table 4).
Knowledge Related to Condom Use
Knowledge about condom use among STD patients was also quite inadequate. Close to 40% of the respondents did not recognize that condoms have expiration dates. About one fourth of the respondents believed that condoms could be reused, and about 21.5% of the males and 33.1% of the females believed that it was appropriate to wear a condom just before ejaculation (Table 4). About 10.8% of the males and 21.2% of the females did not believe that condom use is efficacious for STD prevention (P < 0.05;, Table 4). About 14.4% of the males and 24.0% of the females did not believe that condom use is efficacious for HIV infection prevention (P < 0.05;Table 4). Male respondents in general were more knowledgeable about condom use than female respondents, and males were more likely to believe that condoms are efficacious for prevention of STD and HIV infection (Table 4). Higher education was associated with better knowledge related to condom use (Table 4).
Perceived Susceptibility to STD and HIV Infection
More male than female respondents believed that they might contract an STD in the future (likely or very likely: 30.8% versus 18.0%; data were not tabulated). Age had no effect in this regard, but less education was associated with a greater perceived possibility of contracting an STD in the future (likely or very likely: 20.0% for junior high school education or less, versus 30.1% for senior high school education or more; data were not tabulated).
More than 60% of all respondents believed that they would not contract HIV in the future; fewer than 10% believed that they are susceptible to HIV infection (likely or very likely), whereas the rest gave a “don't know” answer (about 25%; data were not tabulated). Better-educated respondents felt more susceptible, and age had no effect on perceived susceptibility to HIV infection (data were not tabulated).
Factors Associated with Actual or Anticipated Practice of Unprotected Sex with Nonregular Sex Partners Before Cure of STD
With adjustment for age, education, marital status, and rural residence, results of logistic regression analyses showed that male respondents who gave no appropriate answer to the three items included in “other HIV-related properties” (Table 3) were more likely than those males who gave one or more appropriate answers to have either practiced or anticipated practicing unprotected sex with nonregular sex partners before their STD was cured (OR = 2.163; P < 0.05). Similarly, those males who gave two or fewer appropriate answers to the six STD-related questions (listed in Table 4) and those who gave no appropriate answers or only one to the three condom-related questions (Table 4) were more likely to have had or anticipated having unprotected sex with nonregular sex partners before being cured (OR = 2.697 and P < 0.01; OR = 3.725 and P < 0.01, respectively) than were those who gave more appropriate answers to the STD-related questions (at least three) and to the condom-related questions (at least two). In addition, those males who perceived a very high chance of contracting HIV (OR = 7.038; P < 0.05) or an STD in the future (OR = 3.176; P < 0.05) were more likely to have had or anticipated having unprotected sex with nonregular sex partners before being cured than were males who perceived lower chances of contracting HIV or STD (Table 5).
Other risk factors for similar associations with possible risk behaviors before cure of the STD included low perceived efficacy of condoms for HIV infection prevention (OR = 2.439; P < 0.05) and history of STD (OR = 2.047; P < 0.05;Table 5).
For female respondents, only one of the studied variables was significantly associated with having had or anticipated having unprotected sex with nonregular sex partners before cure (OR = 3.517; P < 0.05): the perception of low efficacy of condoms for STD prevention.
Factors Associated with Having Unprotected Sex with Regular Sex Partners Before Cure
For male respondents and after adjustment for background variables, poorer knowledge related to condom use (one or fewer versus two or more appropriate answers: OR = 2.438, P < 0.05), a higher perceived likelihood of contracting HIV (very likely versus likely/unlikely/don't know: OR = 8.628, P < 0.01), a higher perceived likelihood of contracting STD (very likely versus likely/unlikely/don't know: OR = 5.583, P < 0.01), and low perceived condom efficacy for HIV prevention (inefficacious versus efficacious: OR = 2.330, P < 0.05) were all significantly associated with a higher likelihood of having had or anticipated having unprotected sex with nonregular partners before cure (Table 5).
For female respondents, after adjustment for background variables, only two factors were significant in predicting actual or anticipated unprotected sex with regular sex partners before cure: low perceived efficacy of condoms for HIV infection prevention (inefficacious versus efficacious: OR = 3.088, P < 0.05) and low perceived efficacy of condoms for STD prevention (inefficacious versus efficacious: OR = 3.522, P < 0.05;Table 5).
About 70% and 18% of the male respondents had had sexual intercourse with nonregular sex partners or strangers (people they did not know before), and about 30% of them had engaged in commercial sex in the 6 months preceding the interview. The corresponding figures were only 28%, 3.4%, and 2.9% for female respondents. In other words, the majority of the female STD patients might not have been exposed to casual sex or commercial sex (although another 22% said that they had had sexual intercourse with a friend or a colleague). When habits with regular sex partners were addressed, the percentages of consistent condom users were less than 5% for both males and females. A bridging effect between male STD patients and their sex partners is therefore evident. Although many male respondents might have contracted STD from their nonregular or commercial sex partners, a substantial proportion of the female STD patients in southern China may have contracted the disease from their regular sex partners.
Certain factors in China might serve as obstacles to preventing women from contracting STD from their regular sex partners; China is still a traditional and male-dominant country, in which nonmarital sex is more readily accepted among men than among women. The Chinese culture also places women in an inferior position in the negotiation of condom use for STD/HIV prevention. There is a strong need to promote awareness, skills, and empowerment among women to help them participate in decisions about condom use.
Just more than half of the male and female respondents felt that they were not susceptible to a future STD infection, whereas about 20% and 10%, respectively, of the male and female respondents had a history of STD. Even when the STD patients learned about their STD diagnosis, only 20% and 30% or so of the male and female STD patients indicated that they would not practice unprotected sex with a nonregular sex partner before their disease was cured. With the sharp trend of increasing prevalence of STDs all over China, 3 this pattern of spreading STD as a result of unprotected sex before cure would have a cumulative effect on the size of the STD patient population. Therefore, there is an extremely urgent need to break the cycle of further infections.
About 10% of the respondents would practice unprotected sex with their regular sex partners, even after they learned about their own STD and before it was cured. The percentages were much lower than for having unprotected sex with nonregular partners. Such a discrepancy shows that the STD patients were in fact aware of the chance of spreading the STD to their sex partners. They seemed to be much less considerate about having sex with nonregular sex partners. Education to enhance altruism, therefore, would play an important role in the intervention program.
Some misconceptions about STD transmission may be responsible for substantiation of the “STD infection cycles.” About 30% of the respondents believed that STD patients would be immunized from further STD infections; about 50% of them believed that they could not contract two STDs at one time, and more than 50% did not know that some STD patients are asymptomatic but can still transmit STD. With such beliefs, it is not difficult to understand why so many of them would still practice unprotected sex when they were diseased. Some of them might even think that they were having a “safe period.” Such misconceptions were statistically associated with the practice of unprotected sex with nonregular sex partners during the diseased period.
STD patients in China also have very poor knowledge about condom use. Misconceptions about routes of transmission, such as those related to “use of toilet seats,” “kissing,” and “mosquito bites,” were very common (misconception rates were as high as 80% or more for these items). The majority of the respondents were also not knowledgeable about the window period and the asymptomatic property of HIV/AIDS (70–80%).
Therefore, an information campaign on these aspects would contribute much to behavioral changes. Education level was significantly associated with many of the knowledge variables. The STD patients who had attained a lower level of education require special attention. The majority of the STD patients, about 90%, already knew that unprotected vaginal sex, sharing needles, and transfusion of contaminated blood products are routes of HIV transmission.
Those men who had practiced or anticipated practicing unprotected sex with regular and nonregular sex partners before cure had less knowledge related to HIV, STD, and condom use (P < 0.05) and perceived a higher chance of contracting STD or HIV in the future. These associations were not significant for females. Conversely, those men who had practiced or anticipated practicing unprotected sex with regular and nonregular partners before cure were less likely to believe that condom use is efficacious for HIV/AIDS prevention than men who did not anticipate having unprotected sex with their regular or nonregular sex partners. A similar significant association was observed for women who had had or anticipated having unprotected sex with regular sex partners. Promoting the perception of condom efficacy may therefore be important.
China has a long history of dealing with STDs, and it has been related its political and economic development. Around the 1950s, the FSW problem was not recognized; it was stated that there were no FSWs in the new China. STD and its prevention was a sensitive topic. Over time, as China has developed economically and has adopted an “open-up” policy, STDs have increased dramatically, together with different forms of risk behaviors. The Chinese government responded to the problem, and STD surveillance and treatment centers were set up in all geographic areas. The problem needs further attention as the country begins feeling the threat of the HIV epidemic. A revitalized campaign against STD/HIV infection is much needed.
In sum, this needs-assessment exercise clearly documented a very high demand for relevant and effective educational programs for the STD patient population in Guangdong. Special efforts to empower female patients who have contracted STD from a regular sex partner are also required. It is important to curb such infections by providing relevant information and by improving the sense of altruism among male STD patients. The urgency should be recognized in view of the high and increasing STD prevalence in southern China.
The study has several limitations. The sample was not a community-based one, the hospitals were public facilities, and not all public hospitals were included. However, the included hospitals were typical and have large catchment areas in Guangdong. The private medical services system in China is still underdeveloped. Therefore, a majority of the patients are still cared for in the public hospital systems in China. A representative population-based sampling of STD patients, in the absence of any reasonable sampling frame, is almost impossible. Another limitation is that because of the cross-sectional nature of the data, we could only note associations between factors such as knowledge, attitudes, and behaviors rather than explain their causal relationships. Longitudinal and intervention studies would therefore be important and useful.
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