UNTIL RECENTLY, MUCH of the work on HIV/AIDS prevention has directed public health initiatives in the singling-out and targeting of groups and behaviors considered “high risk.”1–10 Consequently, an individualist framework for HIV/AIDS prevention has been developed, which obscures the structural factors that shape the context wherein high-risk groups are formed and high risk-behaviors occur.11 Further, it is an approach that disregards the state's contribution in creating an environment wherein HIV transmission is facilitated or impeded; perhaps, because until now the bulk of infections has been in parts of the world, such as Africa, where the state is comparatively weak. In response, this review seeks to underscore the importance of structural factors in the context of a strong state, such as China.
In recent years, there has been a growing awareness of the potentially massive future HIV/AIDS epidemic in China. This is demonstrated by the plethora of literature available on the subject and epitomized by the World Health Organization's report, HIV/AIDS: China's Titanic Peril.12 China is considered a transitional country with an HIV/AIDS prevalence of 0.1%, but with drastically increasing numbers of infections.13,14 Between 1995 and 2000, the epidemic increased at a rate of 30% per year; in 2001 it augmented by 58% and then shockingly by 122% in 2003. Currently, 840,000 individuals are estimated to be HIV-positive, 80,000 of whom currently have AIDS. Although infections can be found in all 31 of China's provinces, it is predicted that 80% of HIV-positive individuals reside in rural areas. These figures underestimate actual values as current surveillance capacities are insufficient.13–15 Alarmingly, the HIV prevalence rate in China is expected to reach 10 million by 2010.14,15
In analyzing the epidemic, many authors have pointed to the growing numbers of sex workers in China and their potential to generalize the epidemic. The common opinion is that female sex workers (FSWs) may serve as vectors of the disease to an otherwise spared general population.2,16 As a result, much literature in the past 10 years has looked at FSW profiles, risk behaviors, and sexual knowledge to inform targeted public health interventions.2,3,7,10,16–19 Nevertheless, the majority is descriptive in nature and limited in scope. Despite calls for systematic studies of context and group-specific risk factors,7,20 few, if any, articles attempt to look beyond risky behaviors and sexual knowledge (but see Ref. 20). Not negating the importance of such research, focusing solely on such proximal risks, ignores more influential, albeit distal, structural factors in the transmission of HIV/AIDS, while concomitantly stigmatizing FSWs and creating additional obstacles to prevention.
Materials and Methods
This paper reviews the literature on FSWs and HIV/AIDS in China. Automated and manual methods were used for assessing the relevant medical and social literature. As part of the automated method, we used Ovid Medline, Web of Science, PSYCHInfo. CINAHL, ERIC, Healthstar, Science Direct, PROQUEST, Blackwell Synergy, and Oxford to search for articles, editorials, and letters published in peer-reviewed journals from 1980 to 2006. Key words, alone or cross-referenced, used in the searches included China, HIV, AIDS, STD, sexual behavior, FSWs, prostitutes, sex work, sex trade, commercial sex trade, condoms. Grey literature was also obtained from government and multilateral organizations' publications. The manual method included examining the reference sections of reviewed articles as well as the handsearching of 7 relevant journals to identify additional articles. These journals included AIDS, Journal of Acquired Immune Deficiency Syndromes, Sexually Transmitted Diseases, AIDS Care, AIDS Education and Prevention, Social Science and Medicine, and The Lancet. Studies included in this review met the following criteria: (1) conducted in China; (2) focused on HIV and FSWs; or (3) examined the impact of structural factors on FSWs.
The results of this review are presented in a manner that illuminates factors—from the macro- to the microlevel—that condition risk in Chinese FSWs (Fig. 1). We have chosen to highlight state laws and policy, migration, gender, and work organization, as we feel that such factors are particularly relevant to FSWs and underscore the importance of macro- and mesolevel structural factors in creating a high risk environment. We also review better-documented microlevel factors such as the demographic profile of FSWs and risk behaviors.
State Law and Policy
In 1955, China proclaimed the abolition of prostitution as one of the greatest achievements of the new leadership. Additionally, by 1964, China managed to eradicate nearly all sexually transmitted infections (STIs).16,18,21 However, after the Cultural Revolution ended in 1978, China reopened its doors to the world, commencing an era of modernization and economic reforms.22,23 Economic reforms were accompanied by a rural-to-urban migrating “floating population” of 120–140 million people.15,24,25 Sexual networks expanded, and increases in disposable income and changes in traditional sexual “norms” generated the reemergence and expansion of commercial sex work, STIs, and drug trades in China.16,21,26,27 In fact, the number of sex workers has drastically increased from 25,000 in 1985 to 4–6 million in 2000. In 2001, a US State department report on China estimated the number of sex workers to be around 10 million.28
The Chinese government's initial response to the emerging HIV epidemic during the late 1980s was to ban all foreigners with HIV from entering China29 or if already in China, preventing them from crossing between provinces.12,13 This was followed by The Law of Infectious Diseases Prevention and Control in 1989 and the Methods of Implementation of the Law of Infectious Diseases Prevention Control in 1991, which declared AIDS a notifiable disease justifying the quarantine of AIDS patients.12,13 Further legislation issued in 1995 stated that health exams should test for all infectious diseases before marriage; all individuals testing positive should delay marriage until effectively treated and individuals with AIDS were prohibited from marriage.13 Unfortunately, such policies contradictorily acted as a source of heightened HIV transmission, as they stigmatized and discriminated against those infected and may have contributed to a “hidden epidemic” in which patients sought treatment from unlicensed practitioners, leading to antibiotic resistance, untreated STIs, and an increased proliferation of infectious diseases.13,18
In this context, Chinese FSWs have been doubly marginalized, as they are both at high STI/HIV risk and subject to government-sanctioned prosecution. Because prostitution is illegal in China, FSWs are subject to administrative and criminal sanctions.21,30 China's mandatory sex worker reeducation centers12 detain FSWs for 3 months to 2 years and may test them without consent for HIV and other STIs.27 These detention centers teach women about the social evils of prostitution, but until recently, failed to provide information on sexual health or STI prevention.12 Carriers of STIs (including HIV) who engage in “illicit” sexual activities are subject to criminal prosecution and can be sent to prison for 5 years.16,26,31 Seropositive individuals perceived to deliberately spread the disease are also subject to civil and criminal punishment.32 Resultantly, fear of police crackdowns and arrest may lead to FSW mobility, thereby expanding sexual networks and discouraging FSWs from turning to the healthcare system for testing and treatment of STIs and HIV.27 This problem is further compounded by the fact that many FSWs are migrants (see below) and thus already susceptible to mistreatment if caught by the police.7
As of March 2006, China issued the First Comprehensive HIV/AIDS Prevention and Treatment statute. This statute requires local governments to provide confidential HIV testing and antiretroviral drugs to residents and outlaws discrimination against HIV-positive individuals while guaranteeing them a right to healthcare, employment, marriage, and education. Under this new statute, the state requires that all HIV tests be given at no cost and bars officials from disclosing the names or personal information of those who test positive. However, those seen as intentionally transmitting the virus to others will be punished by civil and criminal means.32 Future research should be conducted to assess the implementation and interpretation of this statute at the local level. For the moment, it is unclear as to how this statute applies to highly marginalized populations such as sex workers and migrants. Finally, it should be recognized that although this statute is fairly progressive, it may take some time for the harms of the previous measures to be eliminated.
As Table 1 demonstrates, many FSWs are members of China's floating population—a largely rural-to-urban migrant population that is technically illegal under China's hukou system (household registration system).33 Evidence suggests that the floating population has higher STI and HIV rates than permanent residents.27,34 This is not surprising, given the long acknowledged role of migration and social movement in the spread of HIV.35,36 An exploratory study of the floating population in Shanghai and Beijing indicates that migrants engage in a variety of behaviors that put them at risk of HIV: 47% migrants categorized as “employment seekers”* engaged in sex with multiple partners, 11% always used condoms, 12% sold blood, and 9% reported illicit drug use. Only 14% of all participants in the study identified disease prevention as the purpose of wearing a condom.37 Migration thus intensifies sexual networks through combinations of concurrency and mobility, whereas low condom use facilitates the spread of HIV from higher- to lower-incidence areas throughout China.7,22,26
Migrants in China are thus a subpopulation of special importance for the transmission of HIV38; and the conditions behind, and the process of, migration facilitates risky sexual decisions (such as engaging in commercial sex). Male migrant laborers are known to frequent FSWs (themselves often migrants) and/or establish secondary households, leading to increased incidence of STIs and HIV in locations that often lack adequate healthcare services.27,36 Rural migrant women tend to lack good education and job skills, limiting their job options in an urban environment, and partially explaining why increasing numbers are being recruited into China's sex industry. A recent sample of migrants in Beijing and Nanjing showed that slightly over 6% of migrant women engage in commercial sex, whereas only 1% of the general female population does.30 Given that a higher proportion of migrants engage in sex work (when compared with the general population), and that most studies profile Chinese FSWs as largely migrant,7,10,19,30,38 it becomes difficult to dismiss the role of demographic upheaval (which in-of-itself is linked to changes in economic and governmental policy) in the transmission of HIV/AIDS. Further, it demonstrates that a myopic focus on sexual behavior misses social and economic factors that conditioned the behavior in the first place.
The economic successes achieved in the Post-Mao era have had huge implications for gender relations and gender equality. The emergence of open markets, foreign exchange, and increases in disposable income created new socioeconomic opportunities. However, it also reintroduced gender subordination and oppression in the work force (discrimination, sexual harassment, etc.). This alteration in women's social status and security is epitomized by the return of FSWs to China.21,39 Gender has recently been recognized as an important structural factor shaping HIV transmission; however, most studies continue to focus on the relationship between individual cognitive variables and high-risk behaviors.36,40 Instead, this section argues that the status and opportunities afforded to women help to shape a social context in which FSWs' vulnerability to HIV transmission is heightened and in which they are subjected to increased stigmatization and discrimination.
The concept of vulnerability stems from women's, and thus FSWs', greater probability of acquiring HIV infection when compared with men. Chinese FSWs, as well as Chinese women, are subjected to biologic, cultural, demographic, economic, judicial, and political influences that amplify HIV exposure and transmission by conditioning a high-risk environment.41 At an individual-level, it is impossible to capture the influence of such factors, as is evidenced by a study suggesting that consistent condom users among FSWs (compared with inconsistent condom users) do not differ in individual-level sociodemographic variables, implying that vulnerability to HIV transmission is not solely conditioned by the individual.40 Such work supports studying gender as structural influence on HIV transmission, in that vulnerability to HIV is related to gender equality and gender roles. Because of occupational discrimination, Chinese women are likely to earn less than men or to be the first to be laid off by downsizing state-owned enterprises. To survive, or to supplement their incomes, many women have turned to sex work. With the rapid expansion of privately owned or run business, workplace gender dynamics have changed, often subjecting women to sexual harassment, sexual assault, rape, or forced prostitution. For example, the title of “PR officer” (public relations officer) has become synonymous with “escort service lady” or “company-employed prostitute.”21 Further, the Confucian doctrine of female-to-male submission prescribes societal constraints to women, thus giving rise to increased vulnerability, such as the inability to negotiate condom use with clients.40 Peer influence reinforcing such societal norms may also increase vulnerability.42 Finally, psychological stress, such as being a victim of violence, may further compromise an FSWs' overall health.42–44
It has been stated that “stigma is virtually synonymous with the experience of HIV infection in women,”45 yet few studies seek to illustrate the link between structural factors (such gender roles and equality) and increased stigmatization of FSWs.42,46 It is important to recognize that in societies in which strong cultural and political stigmatizing attitudes prevail, their effects are mostly captured at the individual level.46 However, they are nested in factors above and beyond individual sociodemographic variables.42,46 Within such a framework, stigma is a result of the interaction between difference among population segments, culture, and power.46 Stigma is thus linked to social inequalities and even exclusion affecting FSWs.46 For women, living with HIV implies a life filled with social rejection, discrimination, and violence, thus reinforcing the fear of becoming seropositive,45 which is amplified in the Chinese context in which HIV is thought to be nature's punishment for “bad” behavior.42 Literature on women from traditional cultures suggests an internalization of negative views about HIV, which results in feeling dirty, deadly, and deficient.45 In China, HIV-positive FSWs are viewed as “polluted bodies” and “dregs of society” because they are potential sources of infection to the wider population and to future generations.40,47 This view stems from the popular portrayal of FSWs as either poor girls forced into prostitution or as women who sell their souls for “dirty money.”3 Medical professionals often perceive FSWs as “untrustworthy, immature, promiscuous, irresponsible, inadequate, unnatural, unfit mothers,”47 which is compounded with the general population's belief that HIV-positive individuals should be quarantined in China.42 Stigmatization, therefore, has profound implications for the control of the HIV pandemic in China, as it may dissuade FSWs from consulting medical professionals to determine their HIV status or even acquire the necessary tools to adopt safer-sex behaviors.40,47 Indeed, it has already been associated with a reduced willingness to disclose seropositive status in Chinese women.48 Ironically, the double stigma associated with being a sex worker and a potential vector of disease may actually discourage condom use,49 as FSWs may fear that if they insist on condom use they may be perceived as diseased. Although stigmatization may place FSWs at increased risk, it is important to note that the stigmatization is rooted in society-wide views on gender and in state law and policy. For example, gender inequity in job opportunities and salary creates an environment in which sex work becomes attractive (a recent study suggests that FSWs make more money than their non-FSW counterparts49), and state policies punishing those seen as “intentionally” transmitting HIV may prevent FSWs from seeking medical attention.
According to Huang et al., there are 7 distinct categories of sex worker, with the majority of sexual services being conducted by brothel-based FSWs in karaoke bars, beauty salons, and massage parlors. Other categories include streetwalkers, factory girls, courtesans, and second wives.3 In general, FSWs tend to be 25 years of age or less,7,10,19,50,51 unmarried,7,10,19,50,51 and migrants7,10,16,19,50,51 typically from rural regions.10,16,50,51 The level of literacy amongst FSWs is highly contested,2,12,16,21,27 and the ethnicity varied from province to province7,10,19,50,51 (Table 1).
The type of work organization—the economic and social relationship between the FSW and manager—may largely determine FSWs' motivations to enter and remain in the sex industry. There are 3 common employment arrangements (Table 2). The most often encountered is a combination of housing with work, which entails a relative loss of freedom for the FSW who lives under the watchful eye of the manager/gatekeeper. However, women living under this arrangement have the freedom to come and go as they please, as well as ask for days off.3 In contrast, FSWs may live under semislave conditions, in which they have little personal freedom and may even be locked into the premises. They turn all their earnings over to the manager who provides them with daily necessities in return. These women have usually been intimidated into prostitution or recruited from other cities under false pretences. Finally, there are employment-based FSWs, “free agents,” who are able to choose their managers and play an active role in constructing the rules of the sex trade.3,20
Gatekeepers are defined as persons who manage sex workers; these include mommies, pimps, establishment owners, managers, and other employees.51 They have a reciprocal financial relationship with FSWs20,51 often by providing room and board—with or without a formal salary—in exchange for the services and income generated by the FSWs.3,19,20 Yang demonstrated that perceived gatekeeper support of condom use has been positively associated with condom use communication, frequency, and intention.51 However, it was not associated with proper use of condoms or knowledge of correct condom use.51
Despite the importance of gatekeepers' opinions concerning condom use and STIs, many have negative attitudes toward both, as they fear that forcing clients to use condoms will negatively affect business and that STI education will cause girls to quit.19 Gatekeepers are primarily concerned about making money and not their employees' health, although they are worried about maintaining a healthy appearance amongst their girls.3,19 In a study done on hospitality women in Hainan, gatekeepers taught the girls about hygiene and contraception, although much of this information was incorrect.19 Only about 10% of gatekeepers provided condoms,19 and this is similar to another study done in Guangxi, where only 8% of gatekeepers required condom use. Overall, FSWs' ability to negotiate condom use, types of sexual services provided, and even acceptable clients seemed to be a function of prosperity and work organization, with “free agents” having the most decision-making capacity (Tables 2 and 3). However, in poorer areas, the oversupply of FSWs may decrease bargaining power with gatekeepers and clients, no matter what the type of work organization.3
Surplus Men Equal Surplus Clients
Post-Mao policies have encouraged son preference through the decollectivization of agriculture, the 1-child family planning policy, and the diffusion of ultrasound technology that allows for sex-selective abortion. The result is an estimated 8.5 million surplus men among cohorts born between 1980 and 2000.27 These surplus men are unmarried and disproportionately poor and migrant. They may not be able to afford rising bride prices and will resort to sex workers for sexual services, as the immediate costs of paying a sex worker are less than the long-term investments necessary to find a bride.27
The percentage of adult men visiting sex workers has been reported to be around 9%,27,52 and this percentage may rise as the 8.5 million surplus men become sexually active in the next 10 years.27 Nevertheless, most studies on sex work and HIV focus solely on sex workers and largely ignore the role of the client53 (but see Refs. 52 and 54); yet, it is the client who determines the nature of the sexual encounter,4 and it is the client who may act as a “bridge population” for transmitting HIV to other sex partners.4,27,52 In the few studies that have been done on the clients of FSWs, high frequencies of inconsistent condom use and STIs are reported.4,52–54 For example, the prevalence of HIV, gonorrhea, and chlamydia in a convenience sample of miners in Yunnan province was 0.5%, 0.5%, and 9.3%, respectively. Of the miners who actively sought FSWs, 77.2% did not use condoms. This is similar to the findings of another study conducted in the cities Beijing, Shanghai, and Nanjing, where only 18.5% and 13.8% of clients in 2 convenience samples consistently used condoms in their last 3 sexual encounters.52 However, these are 2 of the few studies that have been conducted on the clients of FSWs in mainland China, and more research is certainly needed.
Similarly, the presence of a regular sex partner in an FSW's life may also be a risk factor for the transmission of HIV, as these partners may have multiple partners, thus enlarging sexual networks.44 However, the literature on Chinese FSWs appears to be unclear on this matter, as it fails to qualify private partners as polygamous. Consequently, there is a vital need for research on the regular partners of FSWs in China.
In assessing the risk of HIV infection amongst FSWs, studies have addressed HIV and STI knowledge,2,3,7,10,19 condom use,2,3,7,10,19,50,51 gatekeeper support,20,51 sexual practices,3,10,19,50 and STI/HIV protection methods.2,3,10,19,50 Because of the diversity of issues addressed and the variety of FSWs studied, few patterns emerge from these studies.
The literature shows that FSWs associate physical appearance with health status. As Table 4 demonstrates, most FSWs felt it sufficient to inspect their clients to prevent STI/HIV infection. FSWs looked at the client to see if he was “clean” or “healthy,” as well as inspecting the genitals to assure that they were “normal.”2,3,10,19 A study by Lau et al. (2002) suggests that a sizable proportion of FSWs do not know that an HIV-infected individual will not immediately fall ill. After visual inspection, vaginal douching and washing were the next most commonly used methods of preventing STI/HIV infection.2,3,19,50 This suggests that public health efforts aiming at reducing HIV/STI transmission need to focus on misconceptions concerning the “healthy client,” and vaginal douching/washing as preventive mechanisms.
The use of condoms by FSWs seemed to vary depending on work organization,3 income,2,3,10 and gatekeeper support.51 Generally, higher socioeconomic class FSWs were more assertive about condom use, used condoms more frequently, and found it less difficult to ask a client to wear a condom (Table 3).2,3,10,20 Further, studies suggest that these higher-class FSWs had fewer clients per week,2,10,51 whereas lower-class FSWs, especially those in semislave working arrangements and had a harder time asking clients to wear a condom, were more likely to never wear a condom, and tended to have more clients per week.2,3,10,19,20
The category of the “second wife” warrants attention in the transmission of HIV/AIDS to the general population. In addition to the day-to-day sexual services provided in Chinese context by FSWs, some clients purchase a longer period of sexual service from a woman. The Chinese often refer to this practice as “hiring a second wife.”19 Occasionally, “second wives” are hired for exclusively reproductive purposes—to give birth to a child, preferably a son.19 China's 1-child family policy may encourage men to seek out a “second wife” to bear them a son. This relationship, however, does not prevent many FSWs from providing services to other clients.19
All studies that looked at FSW condom-usage with their stable partners indicate the frequency is very low,10,19,50,51 typically less than 10%.19,50,51 As a result, “second wives” may serve as a fast conduit in which HIV/AIDS enters the general population by going from client, to FSW, to stable partner or “husband,” to monogamous wife, and to child.
It is evident that FSWs are a vehicle for the transmission of HIV in China, but they are one of many. By labeling FSWs as the vector of the epidemic, they become further stigmatized and marginalized.47 Emphasis on individual high-risk groups detracts attention away from population-wide risk factors such as law and policy, gender roles, and work organization leading, for example, to the creation of an underground STI epidemic. Such structural factors run throughout communities creating an environment conducive to high-risk behaviors amongst the most vulnerable segments of society.
Literature gaps concerning FSWs and HIV transmission occur at macro, meso, and microlevels. At the macro level, there is little literature discussing the role of Chinese policy and law on at-risk populations such as sex workers. Given the strong role of the Chinese state, such research is necessary and timely. For example, in light of the recent Comprehensive HIV/AIDS Prevention and Treatment statute, future research should assess how such a state directive is implemented at the provincial and local levels, and in particular, in relation to marginalized subpopulations (such as FSWs). Further, the contribution of other phenomena at the macro- and mesolevels, such as the greater proportion of males in China, migration, work organization, gate keepers, clients, and stable boyfriends need to be identified if we are to effectively understand and further implement strategies for the prevention of HIV proliferation in China. For instance, China's public health programs often ignore the massive problem of undocumented migrants who have limited, if any, access to health care7 and of whom, a significant number are FSWs and their clients. At the microlevel, public health efforts aiming to reduce HIV/STI transmission need to focus on misconceptions concerning the “healthy client,” and vaginal douching/washing as preventive mechanisms. Finally, researchers should further explore the interrelationship between determinants occurring at multiple levels, such as those between gender, income, working arrangements, and condom use.
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*Categories of floating population in the study included in-transit people (n = 98), restaurant workers (n = 32), street peddlers (n = 196), and people seeking employment (n = 180).37