SEXUALLY TRANSMITTED DISEASES (STDs) are of major public health importance because they predominantly affect young adults, carry stigma, facilitate transmission and acquisition of HIV, and have complications that constitute a great socioeconomic burden. STDs not only are a cause of acute morbidity in adults but also may result in complications with sequelae such as infertility in both men and women. 1 In developing countries, STDs and their complications, even excluding HIV infection, rank among the top five disease categories for which adults seek health care. 2
After the revolution in China in the 1950s, STDs were successfully controlled. The situation changed rapidly when China opened its door to the world in the 1980s; STDs again became a public health problem. 3 In 1993, China set up 26 sentinel surveillance sites for monitoring STDs. From 1993 to 1998, 352,670 cases were reported. The average annual incidence increased from 105/100,000 in 1993 to 234/100,000 in 1998. Most of the reported cases (80–85%) involved persons 20 to 39 years old, the age of highest sexual activity. The major STDs were gonorrhea, genital warts, nongonorrheal urethritis, and syphilis. 4,5 Recently, reported STD cases ranked third among notifiable infectious diseases in China. 6 Like people in other developing countries, those in China have no immunity to the HIV epidemic. The first AIDS case in China was reported in June 1985. The epidemic is now well-established and the infection is spreading. 7 Although the majority of reported HIV infections in China are acquired through injection drug use, heterosexual transmission is increasing and will probably become the dominant mode of transmission. The Chinese are not as conservative in sexual behavior as they once were. Sexual norms in China are changing rapidly, and high-risk sexual behavior that carries an elevated risk of HIV infection/STD is rapidly increasing. 8
Stigmatization, delayed treatment-seeking, and unwillingness to notify spouses and sexual contacts are important issues in STD prevention and control. 9 The perception of stigma blocks the acceptance of community prevention efforts among people at risk and reduces the probability that they will inform their sexual contacts. Both factors cause continued transmission of STDs. STD-related or AIDS-related stigma refers to a pattern of prejudice and discrimination directed at people perceived to have HIV/STDs and often toward their significant others, close associates, social groups, and communities. 10 Currently, the main activities for control of STDs and HIV infection are education to persuade people to adopt safer sex practices and treatment for curable STDs to reduce infectivity. However, successful treatment is constrained by patients’ healthcare-seeking behavior, including delay in seeking treatment and failure to notify sexual contacts. Delaying treatment and failing to notify sexual contacts result in further spread of the epidemic and a high rate of severe complications. 1 Therefore, a reduction in the duration of infection and the promotion of contact notification would reduce the spread of STDs and probably HIV. However, very little is known in China about patients’ healthcare-seeking behavior and the determinants of the delay before seeking treatment for STDs. To understand the healthcare-seeking practices of persons with STDs, we conducted a survey in an urban area in eastern China, querying the factors influencing delay in treatment and failure to notify spouses and sexual contacts, as well as the role of stigmatization. Elucidation of these factors will help in the design of policies and programs to promote early successful treatment of patients with STDs and their sexual contacts.
Hefei is the capital city of the Anhui province and has a population of 1,302,800 (Figure 1). Approximately 78% of the population of Hefei live in urban areas. The gender ratio of females to males is 1:1.12. 11 As in other cities in China, STDs reemerged in the 1980s. The surveillance data for STDs indicates that the annual incidence in Hefei increased from 6.99/100,000 in 1991 to 404.9/100,000 in 1999, a 58-fold increase. 12 Two AIDS cases have been reported in Hefei. Of the 16 STD clinics, 4 urban STD clinics were selected to be studied in Hefei. Two clinics are run by the local health department. The other two are private clinics. The clinics were selected according to the following criteria: (1) at least one new patient per day sought medical service at the clinic; (2) one clinic was chosen in each of the four districts; (3) the STD clinic staff was cooperative.
A cross-sectional study was conducted between May and July 2000. Participants were considered eligible for selection if they had STD symptoms; were male; reported urethral discharge, dysuria, or genital ulcers; and were visiting a clinic for STD treatment for the first time for current STD symptoms. All eligible persons were consecutively invited to participate until the sample size was fulfilled.
After giving informed consent, each participant completed a two-part structured questionnaire. The first part of the questionnaire sought demographic information, knowledge about HIV/STDs, and a selected medical history, including past STDs and current symptoms. Trained interviewers administered the questionnaires in a separate room in which observers were not allowed. The second part of the interview schedule included questions about sexual behavior and was administered with use of a tape player and earphones. 13 All questions and potential answers were prerecorded; the participants used earphones to listen to the questions and marked their responses on a coded answer sheet that did not contain the questions or any identifying information. Each patient was examined by a physician, who established a diagnosis. A copy of the questionnaire is available on request.
Specimen Collection and Testing for Causal Agents
Specimens from patients with urethral discharge or dysuria.
Fifty milliliters of first-catch urine was collected from each patient who had urethral discharge or dysuria. Specimens were stored in clean polypropylene containers without preservatives and kept at −30 °C. Specimens were tested for both Neisseria gonorrhoeae and Chlamydia trachomatis by polymerase chain reaction (Amplicor CT/NG; Roche Laboratories, Branchburg, NJ).
Specimens from patients with genital ulcers.
After lesions in a genital area were thoroughly cleaned with a sterile swab, material from the base of the largest lesion was collected on a cotton-tipped swab. The swab was vigorously agitated for 15 seconds in a collection tube containing transport medium and was then frozen at −30 °C. Polymerase chain reaction tests were performed to detect herpes simplex virus (HSV) and Haemophilus ducreyi. In addition, 10 ml of venous blood was obtained and tested for syphilis serology by rapid plasma reagin testing (RPR test kit; Urumoqi, Urumoqi, China), and the results were confirmed with TPPA (Serodia; Fujirebio, Inc., Tokyo, Japan).
All specimens were transported to the China National Center for STD Control and Prevention for testing.
All data were entered into a computerized database with use of Epi Info 6.12 software (Centers for Disease Control and Prevention, Atlanta, GA). Bivariate analysis and multivariate logistic regression analysis were performed to estimate crude odds ratios, adjusted odds ratios, and their 95% CIs, with use of SAS software (version 8.01; SAS Institute, Cary, NC). Patients who requested confidentiality from the STD clinic staff, preferred to go to the clinic at night, or were afraid to be seen at the clinics were classified as feeling stigmatized. Patients who sought medical care 1 week or more after the onset of symptoms were classified as delaying treatment. There were 16 questions about knowledge of HIV/STD symptoms, transmission, and prevention (Appendix). One point was given for each correct answer. Thus, the highest possible score was 16 points. If neither N gonorrhoeae nor C trachomatis could be identified by laboratory testing, patients with urethral discharge or dysuria were classified as having “other urethral discharge,” whereas patients with genital ulcers who did not test positive for H ducreyi, syphilis, and HSV were classified as having “other genital ulcers.”
Description of the Study Population
A total of 417 eligible subjects were invited to participate in the study, 11 (3%) of whom refused to participate. Thus, 406 men who had genitourinary symptoms were interviewed. Table 1 presents the demographic characteristics, STD symptoms, and diagnosis by study sites. The majority of participants were married, had achieved middle school or higher education, and were private businessmen. Three-hundred fifty patients (86%) reported urethral discharge or dysuria, and 55 (14%) reported genital ulcers. One patient (0.3%) had both urethral discharge and genital ulcers.
From patients with urethral discharge or dysuria, 347 urine samples were collected (urine samples could not be obtained from 3 patients). One hundred fifty-eight had gonorrhea, 28 had chlamydia, 54 had both gonorrhea and chlamydia infection, and 107 had “other urethral discharge.” Among patients with genital ulcers, 13 had syphilis, 15 had HSV infection, 0 had H ducreyi infection, and 27 had “other genital ulcers.”
The majority (80%) of the men felt stigmatized. Table 2 shows the distribution of stigmatization, stratified by selected variables. Patients who had a university education and a higher score for HIV/STD knowledge were more likely to feel stigmatized. The level of stigmatization was similar among the different strata of the other selected variables.
Duration of Symptoms Before Seeking Treatment
Overall, 28% of the patients had been symptomatic for longer than 1 week before seeking treatment; 17% had symptoms for more than 2 weeks. Men with both gonorrhea and chlamydia infection were more likely to seek treatment within 1 week, whereas men with “other urethral discharge” tended to wait longer to seek treatment (Table 3). The median delay in seeking treatment was 5 days for all patients, 7 days for patients with genital ulcers, and 5 days for patients with urethral discharge or dysuria.
Factors Associated With Delay in Seeking Treatment
On bivariate analysis, a longer delay in seeking treatment was associated with higher education, greater HIV/STD knowledge, having had sex with other partners in the previous 3 months, having “other urethral discharge,” being positive for HSV or syphilis, and having “other genital ulcers” (Table 4).
The results of the multivariate logistic regression analysis indicated that those who had a university education or had sex with other partners in the previous 3 months were more likely to seek early treatment. Those who had “other urethral discharge” or had syphilis or HSV were more likely to wait longer to seek treatment. The perception of stigma was not associated with a delay in treatment (Table 4).
Reasons for Delay in Seeking Treatment
Patients who delayed seeking treatment were asked the reasons for their delay. The most common reasons reported were that it did not make any difference to wait for a while (69%), that they were afraid to be seen by others (53%), and that they worried about the high cost of medical treatment (35%; all patients in China must pay for treatment). Thirty-four patients (32%) reported that they preferred to go to a drugstore for medication instead of a clinic.
Among patients who currently lived with their spouse, only 64 (23%) indicated a willingness to inform their spouse of their STD status. Sixty-one patients who had had an STD episode within the past year were asked if they had notified their spouse of their STD status; 13 (21%) reported that they had.
Univariate analysis indicated that unwillingness to inform a spouse was associated with feeling stigmatized and with the patient’s level of education. Multivariate analysis confirmed that feeling stigmatized was associated with the unwillingness to inform the spouse (Table 5).
Had Sex During Symptoms
One hundred sixty-four men (40%) reported having sex after the onset of STD symptoms: 123 (45%) of the 276 married men, 26 (27%) of the 98 single men, and 15 (47%) of the 32 cohabiting or divorced men. One hundred two (83%) of the married men who had sex after the onset of symptoms continued to have sex with their wives, and 70 (57%) of them also had sex with other women (Table 6). Among patients with urethral discharge or dysuria, 40% (139/350) reported having sex after the onset of symptoms, as did 46% (25/55) who had genital ulcers (chi-square test value = 0.49;P = 0.49).
Because the duration of infectivity is a key variable in STD transmission, ensuring prompt and effective treatment of infected individuals is an essential public health measure. This study underscores that delaying treatment-seeking is a problem. Many men delayed seeking treatment for longer than 1 week and continued to engage in sexual activities with their wives and other women. The lengths of delay are less than reported in other studies, 14,15 perhaps because all of the patients in the current study were attending an STD clinic for the first time for the current episode and were more likely to have symptomatic diseases. This study indicated that people who had less education tended to delay seeking treatment longer. Thus, public messages to reduce STDs need to target men with less education, and the messages need to be simple and direct. Having had premarital/extramarital sex also influenced the men’s decisions to seek treatment; that is, those who had premarital/extramarital sex tended to seek treatment sooner, perhaps reflecting a higher perception of vulnerability associated with their own risky sexual behavior. This result is comparable to that reported after a study in Kenya. 15
Patients who had genital ulcers waited longer to seek treatment than those who had gonorrhea and chlamydial infection. The difference may be due to the relative severity or discomfort. The incubation period for early syphilis is long—an average of 3 weeks—but can be anywhere from 10 to 90 days from exposure to onset of symptoms. Since genital ulcers, especially among men, have a strong interactive effect on HIV transmission, 16 decreasing the period of STD infectivity is an important public health goal in the prevention of HIV.
Although the association between HIV/AIDS/STD knowledge and promptness of treatment-seeking does not reach statistical significance in multivariate analysis, the trend still suggests that patients with higher scores were more likely to seek early treatment. A recent study indicated that the level of community awareness of HIV in Anhui was extremely low. 8 Thus, more education is needed to recognize STD symptoms, the potential consequences of STD infection, and the complications and consequences caused by delaying treatment-seeking. The perception of stigma was not statistically associated with such delays. Fortenberry 17 reported that the perception of stigma related to STDs was associated with adolescent females’ delay in seeking health care but that this was not so for adolescent males. Possible explanations are that the elimination of discomfort due to an STD and normalization of community activities among men outweigh the fear of stigmatization associated with STDs. The previous occurrence of STD was not predictive of healthcare-seeking behavior. This finding is similar to those in previous studies. 18–20 The patients in the current study who had had an STD previously were asked if they had ever received health education. Only 52% had received any education when they sought treatment. Thus, despite their experience with STDs and the health care associated with such diseases, the men still did not understand the importance of early treatment, perhaps in part because of a lack of appropriate counseling.
Promotion of healthcare-seeking behavior should be directed not only at those with symptoms of STDs, but also at those with an increased risk of acquiring STDs, including HIV infection. Education of those who are at high risk is an important strategy for prevention of secondary infection and reduction of potential STD/HIV reservoirs. Partner notification, i.e., the notification, counseling, examination, and treatment of sex partners of patients with STD, is an important public health activity. 21 Patients should be encouraged to make sure that all sex partners who are accessible receive treatment. Regardless of its importance, published information on this issue is scarce in China, where STD infection is spreading very rapidly. Patients may not notify their sex partners because of fear, embarrassment, or ignorance of its importance. In the current study, the majority of subjects (77%) did not even notify their spouse of their STD status. Multivariate analysis indicates that stigma has a strong independent influence on the willingness to notify sexual contacts. The patients probably perceived that the admission of extramarital sexual activity and infection would cause a negative response from their family members and possibly break up the family. This explanation is supported by the results of a survey of rural residents in which discrimination and family unification were two key factors influencing the subjects’ decisions to disclose HIV test results to their spouses. 22 In developing countries, men have primary power in households; thus, wives may be unable to refuse to have sex with their husbands. Consequently, they are at risk of infection from their husbands. A recent study by Parish et al. 23 indicated a high degree of infection in women married to men with higher socioeconomic status. Without notification, sexual contacts of the primary cases may spread their infection to others. About 40% of patients engaged in sexual intercourse between the onset of symptoms and treatment-seeking. Thus, they continued to put their spouses and other sexual contacts at extremely high risk of infection.
Many of the obstacles to the prevention of STDs at both the individual and population levels are directly or indirectly attributable to the social stigmatization associated with STDs. 24 Stigmatization and discrimination against STD-infected people undermines the ability of individuals, families, and societies to protect themselves and provide support and reassurance to those infected. 25 In many places, ordinary citizens are still reluctant to recognize or acknowledge the relevance of STDs, HIV, or AIDS to their own lives and the impact of discrimination on those infected and on the entire community. People with or suspected of having an STD may be turned away by society and even thrown out by their spouse or family. Thus, most people fear telling their spouses or other partners that they have an STD. If people are afraid to acknowledge or even find out that they are infected, transmission will continue. If couples cannot talk about the risks that either one may have taken, it is subsequently difficult for either partner to bring up the issue of condoms or STD testing as a way of preventing further spread of the virus to their spouses or children. This study shows that the majority of patients felt stigmatized and were not willing to inform even their spouses regarding their status. Thus, it is crucial that the stigma associated with STDs be directly confronted by means of health education, the media, and social leaders. Acknowledgment that premarital/extramarital sex is not uncommon is a first step, allowing sexually active people to prevent transmission through use of condoms and testing for STDs.
The limitations of the findings should be emphasized. Because STD patients seen in STD clinics in a single city do not represent all STD patients, the findings may have limited generalizability. Most of the information obtained was solely based on self-reporting; it was difficult to validate the accuracy of responses. However, the tape player technique was used to enhance patients’ trust in the confidentiality of the study. Consequently, the validity of the responses was probably increased. The use of the tape player with earphones has been shown to yield more self-reports of extramarital sexual activity and other high-risk sexual behavior. 13
Our findings have important implications for STD control programs. Our findings suggest that many STD clinics do not provide counseling to prevent reinfections. STDs are spreading rapidly throughout China. HIV infection through sexual contact is also increasing. Given that STDs have a strong synergic effect on HIV infection, STD control programs should be effectively integrated into HIV infection prevention efforts and should always include counseling. It is important that individuals who have symptoms of STDs be made aware that they must seek treatment promptly and refrain from sexual activity until they have been effectively treated. Education massages should be understandable to the target audiences and appropriate within local contexts. This will require intensive education efforts to increase the awareness of sexually active people to change their sexual behavior by practicing “safer sex” and to reduce stigmatization of sexually active people. In order to reduce STDs, STD prevention and control programs need to promote partner notification among both patients and physicians, and the effectiveness of partner notification must be evaluated. In addition, confidentiality should be enhanced in all medical facilities. Although China is a relatively conservative nation, the elimination of stigma must be a priority. While increasing patients’ recognition of STDs and awareness of the severity of the consequences in delaying treatment-seeking, education efforts should discourage misconceptions and STD-related stigmatization.
In conclusion, delays in seeking treatment, perception of stigma, and failure to notify sexual contacts (including spouses) are major interrelated problems among male patients with STDs. These factors not only put patients themselves at risk of severe complications but also facilitate the further spread of STDs and HIV infection/AIDS. Intensive education and effective counseling targeting the improvement of disease notification, reduction or elimination of stigma, and higher rates of sexual contact notification should be available to patients with STDs, sexually active people, and the general population.
Possible answers to the following questions were “true,” “false,” and “do not know.”
Questions on Knowledge of STDs
- 1. Sexually transmitted diseases (STDs) are mainly transmitted through sexual contact.
- 2. People who have sex with prostitutes are at a high risk of getting STDs.
- 3. Once an STD is cured, a person is immune to further STDs.
- 4. Condoms provide protection against STDs.
- 5. If a woman does not show signs of STDs, it is safe to have sex with her because there is no risk of getting the infection from her.
- 6. It is impossible to have gonorrhea and syphilis at the same time.
- 7. People who have STDs are at a high risk of getting HIV infection.
Questions on Knowledge of HIV Transmission
HIV is transmitted by:
- 1. Sharing needles with other drug users
- 2. Sexual contact
- 3. Kissing
- 4. Living together
- 5. A mother to her infant
- 6. Blood transfusion
- 7. Air, like the flu
- 8. Holding hands
- 9. Mosquito bite.
1. WHO/UNAIDS. Sexually transmitted diseases: policies and principles for prevention and care. Geneva: World Health Organization/UNAIDS, 1995.
2. UNAIDS. The public health approach to STD control: UNAIDS technical update. Geneva: UNAIDS 1998.
3. Cohen MS, Henderson GE, Aiello P, Zheng H. Successful eradication of sexually transmitted diseases in the People’s Republic of China: implications for the 21st century. J Infect Dis 1996; 174 (suppl 2): S223–229.
4. National Cooperative Group Of Sexually Transmitted Diseases Surveillance. Preliminary sexually transmitted disease epidemiological analysis at national sentinel surveillance sites (1993–1996). Chung Kuo I Hsueh Ko Hsueh Yuan Hsueh Pao 1998; 6: 30–33.
5. Chen X, Gong X, Liang G, Zhang G. Epidemiologic trends of sexually transmitted diseases in China. Sex Transm Dis 2000; 27: 138–142.
6. Wang S, Wang S, Tang D. Analysis of STD epidemic in China: STD prevention and control. Beijing: Chinese Technique Press, 1996.
7. Yu ES, Xie Q, Zhang K, Lu P, Chan LL. HIV infection and AIDS in China, 1985 through 1994. Am J Public Health 1996; 86 (8 Pt 1):1116–1122.
8. Liu H, Xie J, Yu W, et al. A study of sexual behavior among rural residents of China. J Acquir Immun Defic Syndr Hum Retrovir 1998; 19: 80–88.
9. Aral SO, Wasserheit JN. STD-related health care seeking and health service delivery. In: Holmes KK, ed. Sexually Transmitted Diseases. 3rd ed. New York: McGraw–Hill, 1999: 1295–1305.
10. Cogan J, Herek G. Stigma. In: Smith RA, ed. Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic. Chicago: Fitzroy Dearborn, 1998: 466–467.
11. Anhui Statistics Bureau. Anhui Statistical Yearbook. Beijing: China Statistical Publishing House, 2000.
12. Li X. Epidemiological analysis on STDs in Hefei from 1991 to 1999. In: AIDS/STDs Report. Hefei, Anti-Epidemic Station, 2000:23–26.
13. Liu H, Detels R. An approach to improve validity of responses in a sexual behavior study in a rural area of China. AIDS Behav 1999; 3: 243–249.
14. Hook EW III, Richey CM, Leone P, et al. Delayed presentation to clinics for sexual transmitted diseases by symptomatic patients. Sex Transm Dis 1997; 24: 443–448.
15. Moses S, Ngugi EN, Bradley JE, et al. Health care-seeking behavior related to the transmission of sexually transmitted disease in Kenya. Am J Public Health 1994; 84: 1947–1951.
16. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75: 3–17.
17. Fortenberry JD. Health care seeking behavior related to sexually transmitted diseases among adolescents. Am J Public Health 1997; 87: 417–420.
18. Leenaars PEM, Rombouts R, Kok G. Seeking medical care for a sexually transmitted disease: determinants of delay-behavior. Psychol Health 1993; 8: 17–32.
19. Nuwaha F. Factors influencing timing of seeking health care among patients with sexually transmitted diseases in Kampala, Uganda. Centr Afr J Med 1999; 45: 320–323.
20. Gott CM, Rogstad KE, Riley V, Ahmed-Jushuf I. Delay in symptom presentation among a sample of older GUM clinic attenders. Int J STD AIDS 1999; 10: 43–46.
21. World Health Organization. WHO consensus statement: partner notification for preventing HIV transmission. J Sex Res 1989; 26: 393–399.
22. Liu H, Ma Z, Yu W, Xie J, Detels R. Acceptability of voluntary HIV testing and result disclosure among rural residents of China. J Chinese Prev Med 2001; 35: 30–32.
23. Parish WL, Laumann EO, Cohen MS, et al. The resurgent epidemic of STDs in China: a population-based study of the behavioral and demographic correlates and implications for public health policy. Int J STD AIDS 2001; 12 (suppl 2): 74.
24. In: Eng TR, Butler WT, eds. The hidden epidemic: confronting sexually transmitted diseases. Washington DC: National Academy Press, 1997:86–108.
25. Meron M. Discrimination against HIV infected people or people with AIDS: speech to Commission on Human Rights. Geneva: World Health Organization/Global Program on AIDS, 1993.