SEXUALLY TRANSMITTED DISEASES (STDs) were virtually eradicated in China in the 1960s, 1–3 but reemerged in late 1970s. The increase in the incidence and prevalence of STDs was dramatic during the 1980s and 1990s 4–7; between 1990 and 1998, STD incidence in China increased 4.2 times among females and 3.8 times among males. 7 Aside from the morbidity of these diseases, their rapid spread could enhance HIV transmission in China. Sexually transmitted diseases, particularly those that cause genital ulceration, significantly increase the likelihood of HIV infection, 8–12 and the spread of STDs suggest that more Chinese residents are engaging in high-risk sex behaviors. Indeed, there has been a substantial growth of HIV infection through sexual transmission in China. 13,14 For example, the proportion of HIV infection acquired through sexual transmission nationwide has almost tripled from 5.6% in 1991 to 15.7% in 1993. 14 Some researchers suggest that “sexual contact is becoming the main mode of HIV transmission in China.”14 Without effective prevention, the estimated HIV infections in China could reach 10 million by the year 2010. 15,16
Studies about AIDS and HIV prevention among STD patients have been rare in China, and were primarily limited to assessing HIV status of STD patients 17–19 and the delayed treatment for the diseases. 20 Little is known about sex practices that increase the risk of contracting HIV infection or the level of HIV and AIDS knowledge among STD patients in China.
This report provides results from a study recently conducted among patients attending a STD clinic in China that examined their level of AIDS and HIV knowledge, self-reported sex practices, and condom use practices. The study was a collaborative effort between researchers at Wright State University and Shandong Medical University, China. The study was approved by the Institutional Review Boards of both researchers, and by the People’s Republic of China Ministry of Health.
Methods
Sample
From April 12, 1998 to October 31, 1998, 498 STD patients who visited the Center of Prevention and Treatment of STD and Skin Disease (CPTSSD) in Jinan, the capital city of Shandong Province, China, were randomly chosen to participate. The sampling strategy was based on a time and space random sampling design, with which a time unit of 1 week was defined as the primary sampling unit. 21 Twenty primary sampling units were randomly sampled from an observation period with a probability proportional to the estimated number of unique visitors in each primary sampling unit. Then, a fixed number of persons (25) were randomly selected from the STD patients who visited CPTSSD in each selected week.
The participants who were identified in CPTSSD records as having an STD, were not infected with HIV, and did not have AIDS were eligible to participate in the project. If a patient selected expressed interest in participating, he or she was interviewed by a CPTSSD physician. For those who finished the anonymous interviews, which lasted approximately 1.5 to 2.0 hours, £60 Yuan (≈ US $7) were paid to compensate them for their time. Individual information was kept confidential. The Sex Risk Behavior Assessment questionnaire, an instrument developed especially for the project, was used for the interviews, and collected information regarding a host of variables (e.g., STD history, HIV and AIDS knowledge, sex practices, and condom use). A copy of the questionnaire is available from the authors upon request.
Data Analysis
Univariate statistics were used to describe the sociodemographic characteristics, AIDS and HIV knowledge, sex practices, and condom use in the 12 months before interview. Logistic regression models were used to assess the correlates of condom use when having sex with a spouse, boyfriend or girlfriend, and other sexual partner. Because too few subjects reported always using condoms, risk behavior (i.e., “never using condoms”) was modeled in the logistic regressions rather than protective behavior. Residence (urban versus rural), ethnicity (Han nationality versus minority nationalities), gender (male versus female), education (less than high school, high school, and college), AIDS and HIV knowledge (proportion giving correct answers to 13 basic AIDS- and HIV-related questions), and sex partners (having multiple sex partners versus having a single sex partner) were used as predictors in the logistic regression models.
Results
The demographic characteristics of the sample are shown in Table 1. The majority of the sample was male, and most of the patients were urban residents. The male patients were older (mean age 33) than female patients (mean age 27). A substantial proportion of the patients had never been married (about 28.7% for men and 34.0% for women).
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Table 1: Demographics of the Sample
The most commonly diagnosed STDs in the sample were chlamydia, gonorrhea, and genital warts. Approximately 24% of females also reported vaginal candidiasis (see Table 2).
Table 2: Diagnosed STDs Among STD Clinic Patients, by Gender
The level of AIDS and HIV knowledge among these patients was low. For the 13 basic AIDS and HIV related questions (see the notes in Table 3), the proportion of giving correct answers to all the questions was approximately 44.3% among women and 53.4% among men. The majority of patients (87% of males, and 54% of females) reported having had multiple sex partners in the 12 months before the interview. The mean number of sex partners in the sample was 6.2 for males and 7.2 for females.
Table 3: AIDS/HIV Knowledge* Among Sexually Transmitted Disease Clinic Patients, by Gender
Table 4 shows sex partnership and condom use by gender. Among the 348 men in the sample, 207 (59.5%) reported having sex with a spouse, 119 (34.2%) reported having sex with a girlfriend or girlfriends, and 311 (89.4%) reporting having sex with other sex partners in the 12 months before interview. The corresponding figures for women were 80 (53.3%), 75 (50.0%), and 50 (33.3%), respectively, in the same period. When having sex, few men and no women reported always using condoms. When having sex with a spouse, a majority (> 60%) of all patients reported never using condoms. When having sex with a boyfriend or girlfriend, 48.0% of the women and 40.3% of the men reported never using condoms. Approximately 68.5% of men reported never using condoms, compared with only 26.0% of women when having sex with others.
Table 4: Condom Use Among STD Patients by Gender (Past 12 Months)
Table 5 shows the results of logistic regression models. In the first, the odds of never using condoms when having sex with spouse in the 12 months before the interview was modeled; only age and AIDS and HIV knowledge showed a significant effect on the odds of never using condoms. Older people were more likely to never use condoms (odds ratio [OR], 1.06; 95% CI, 1.01–1.10), and AIDS and HIV knowledge helped reduce the likelihood of never using condoms when having sex with a spouse (OR, 0.98; 95% CI, 0.97–0.99). Results in model 2 show the associations between the predictors and the odds of never using condoms when having sex with a boyfriend or girlfriend. Again, age was significantly and positively associated with the odds of never using condoms, whereas the effect of AIDS and HIV knowledge disappeared. In addition, men were less likely to never use condoms when having sex with a girlfriend compared with women when having sex with a boyfriend (OR, 0.33; 95% CI, 0.16–0.69). Those who had multiple sex partners were much more likely to never use condoms when having sex with a boyfriend or girlfriend (OR, 4.64, 95% C.I.=1.72–12.53). The associations between the predictors and the odds of never using condoms when having sex with other sex partners were examined in model 3. The results show that urban STD patients were less likely than rural patients, while men were more likely than women, to never use condoms when having sex with other sex partners in the past 12 months (OR, 0.41; 95% CI, 0.19–0.86) (OR, 7.51; 95% CI, 3.41–16.53). The odds of never using condoms was much smaller for patients with multiple sex partners than for those with a single sex partner (OR, 0.27; 95% CI, 0.07–0.98). Again, AIDS and HIV knowledge was important in reducing the odds of never using condoms when having sex with other sex partners (OR, 0.98; 95% CI, 0.98,0.99).
Table 5: Results of Logistic Regressions on the Odds of Never Using Condoms When Having Sex (Past 12 Months)
Discussion
In Jinan, Shandong, STD patients had low levels of knowledge about AIDS and HIV, but were sexually active and engaged in high-risk sexual behaviors in the12 months before the interview. The majority of the patients had multiple sex partners, and condom use was rare. Four factors (residence, gender, having multiple sex partners, and the level of AIDS and HIV knowledge) were significantly associated with never using condoms when having sex with other sex partners. Age became an important predictor for the odds of never using condoms when having sex with a spouse or a boyfriend or girlfriend, whereas the effects of some other factors disappeared. For example, residence and the level of AIDS and HIV knowledge did not show significant effects on the odds of never using condoms when having sex with a boyfriend or girlfriend; gender and having multiple sex partners showed no effect on the odds of never using condoms when having sex with a spouse.
The study was based on a sample from one STD clinic in China, which limits the generalizability of the results. Regardless, these findings raise concern about the potential spread of STDs, AIDS, and HIV in China. The high-risk sex practices of these patients could result in the spread of STDs, including HIV, to their sex partners. More research is needed to better understand the factors relevant to the development of risk-reduction interventions for STD patients in China.
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