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Metrics details. In addition, 32 HIV-positive CFSWs were recruited to participate in in-depth interviews 18 participated in both, 14 participated in-depth interviews only to explore reasons for extramarital sexual behaviors and inconsistent condom use.

The quantitative data on sexual risk behaviors were analyzed using chi-square tests. Interviews were coded inductively for emerging themes.

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Among the participants of the quantitative survey, HIV-positive CFSWs continue to practice unsafe sexual behaviors with regular and irregular partners after HIV diagnosis, but were more willing to protect their regular partners. Future interventions targeting HIV-positive CFSWs should not only be confined to sero-discordant couples, but also need to instill a sense of responsibility to protect the commercial and casual partners and reduce the of concurrent partners.

Peer Review reports. In China, the sexual transmission of HIV is rapidly increasing [ 12 ]. Heterosexual transmission ed for More so, behavioral interventions typically aim to prevent new infections among key affected populations, rather than focusing broadly on all PLHIV [ 1 ]. Owing to rapid changes in sexual behaviors and China female sex over the past three decades, extramarital sex and concurrent sexual relationships are increasingly common in China [ 8 ].

Therefore, current interventions may not adequately address the range of sexual relationships PLHIV may have. In4. The large s of clients of female sex workers CFSWs that fuel the flourishing sex industry are likely to play an important role in heterosexual transmission of HIV. CFSWs have a high HIV and sexually transmitted infection STI prevalence, low consistent condom use rate, high rates of partner exchange or concurrent sexual partners, and decisive power on safe sex [ 10111213 ]. For example, a study of clients in Sichuan found that the syphilis prevalence was 8.

After being diagnosed with HIV, interventions shift to preventing secondary transmission. Despite the need to understand the behaviors and relationships of HIV-positive CFSWs that shape secondary transmission [ 14 ], there are no studies specifically focusing on this group in China.

In this study, we used mixed methods to examine current sex behaviors, relationships, types of partners, China female sex unprotected sex among different sexual partners of HIV positive CFSWs, in order to understand the reasons for unsafe sex behavior. Current sexual risk behavior and associated factors were first collected by a questionnaire. The context of sexual relationships and condom use were explored through semi-structured, in-depth interviews.

After analyzing the quantitative and qualitative data separately, we merged the of the two strands to describe the sexual risk behavior of HIV positive CFSWs.

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Changsha and Hengyang are adjacent, and are the capital city and the second largest city in Hunan Province in central China. The sex industry in both cities includes a variety of sexual service venues; including nightclubs, karaoke parlors, hotels, bathhouses, hair salons, massage parlors, and roide restaurants. First, all HIV positive heterosexual men were identified by outpatient doctors at an ART outpatient clinic, or through reviewing clinic medical records which record the route of HIV transmission. Second, any of the above men who reported having unprotected sex with a FSW before his HIV diagnosis and also denied the possibility that his regular partner transmitted HIV to him, were included.

Third, HIV positive heterosexual men who China female sex reported having no history of injection drug use or having anal or oral sex with men before their HIV diagnosis were considered. In addition to meeting the above inclusion criteria, the participants were first sampled to maximize differences in age, occupation, education, and sexual behaviors after HIV diagnosis.

Participants were then sampled purposively according to the purpose of the study. Trained study staff administered a structured questionnaire during face-to-face interviews in a private room in ART clinics or local Centers for Disease Controls CDCs study sites.

Staff were trained on China female sex purpose of the study, informed consent, and the requirements for conducting the study. Regular sexual partners were defined as a spouse or long-term sexual partner with whom the participant had regular sex without monetary compensation. Commercial sexual partners referred to female sex workers FSWs to whom the participant was required to pay money to have sex, and a casual partner was someone with whom the participant had sex with occasionally without compensation.

In the qualitative study, 32 participants were interviewed in private rooms at ART outpatient clinics in Hengyang. These interviews explored attitudes and reasons for extramarital sex and unsafe sex behaviors amongst PLHIV. A total of 32 participants took part in semi-structured, in-depth interviews and 18 of these participants had also completed the questionnaire during the quantitative survey. All interviews were audio recorded. Interviews were conducted until data saturation was reached. Interview excerpts were translated separately by the first two authors WPL and WMD, a native English speakerand then discussed to choose the best translation, which was verified by another author ZC proficient in both English and Chinese.

Descriptive demographic variables, ART status, and risky sexual behavior were presented as categorical variables. Sexual behavior among different sex partners was compared with a chi-square test. Digitally recorded interviews were transcribed verbatim and checked against the original audio recording for accuracy. Data analysis was conducted simultaneously with data collection.

Line-by-line initial coding was performed first on transcribed interviews, and codes were developed based on emergent themes. A codebook was then developed and these codes were applied to the rest of the transcripts. Additionally, theoretical memos were written to explore emergent themes. All participants provided written consent. We recruited and interviewed CFSWs. Among them, CFSWs The mean age of the sample was More than one-fifth of the participants had not finished nine years of compulsory education.

In addition, over four-fifths of the participants were receiving ART Table 1. Of the participants, Only One-quarter of HIV-positive clients The mean age for first sexual behavior was Among the married or ever married participants, The mean age for first purchase of commercial sex was Before their HIV diagnosis, Consistent condom use over the past six months was Table 4 displays these findings in relation to condom use. Quotes were chosen to be representative of the emerging themes and provide authenticity to the. Almost all participants reported that extramarital sexual behavior, including sex with both commercial and noncommercial partners, was popular among their social networks.

Extramarital sexual behavior was perceived positively among peers, serving as a means of conversation and gloating. Participants reported various motivations for having extramarital sex; including meeting their physiological needs; to add excitement to a monotonous life; peer pressure; or as part of banquets where business China female sex build relationships through dining, drinking, and engaging in sex with FSWs. Though participants knew using condoms could prevent HIV transmission, many CFSWs reported that after becoming diagnosed with HIV, they stopped having sex with their wives as they saw abstaining from sex with their wives as essential to prevent infection.

Participants reported a lack of partners and an inability or unwillingness to have sex with their regular partners as important reasons for having sex with FSWs. How can I let off [my libido]? Two participants reported having casual, non-commercial partners.

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An unmarried young man who had broken up with his girlfriend before his HIV diagnosis did not feel ready to date after becoming infected. He felt hopeless, as he thought no girls would be willing to be his girlfriend or marry him if they knew he was infected with HIV. In order to fulfill his sexual needs, he found one-night lovers on a popular instant messaging app. A married man found an HIV-positive partner with whom he could share feelings, as he felt that his status produced a barrier to intimacy with his HIV-negative wife. He initiated a relationship with a woman he had seen at an ART clinic because he wanted a partner who also had the disease to communicate with.

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Table 4 presents models for consistent condom use with different types of partners. After being diagnosed, married participants used condoms consistently with their HIV negative spouses. The only participant who did not use condoms with his wife concealed his status China female sex her, and did not know her HIV status. He explained after his first wife died, he remarried but he and his second wife did not have a strong emotional attachment.

With FSWs, participants reported they used condoms consistently to avoid infecting others. The one participant who never used condoms reported that he usually went to bath houses or massage parlors one to two times monthly, which had been greatly reduced compared to before his HIV diagnosis. Condom use with FSWs was also framed as a matter of conscientiousness liangxin and overall quality of the individual suzhi.

The of this qualitative study add context and meaning to the outcomes of the quantitative assessment. The rate of condom use was two times higher among participants engaging in sexual relations with regular partners compared to commercial sex workers. The in-depth interviews conducted in this study help elaborate on potential reasons and understandings for such behaviors. Our mixed-methods study found that clients continued to practice extramarital sex and low rates of consistent condom use, which placed both their regular and casual sexual partners at risk of infection.

Additionally, consistent condom use varied by type of partner. The qualitative suggest that interventions need to address the emotional and sociocultural factors underpinning these disparities in condom use.

The qualitative data may explain this difference.

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In the interviews, participants described feeling a strong sense of responsibility to protect their family from the consequences of their infection and the prioritization of family obligations. In contrast, because commercial or casual sexual partners are outside of the family, clients did not feel a sense of obligation. However, the low rates of condom use in commercial sex settings indicates that a stronger and culturally resonant sense of obligation to protecting other partners needs to be instilled.

Factors such as perception of HIV risk, which have been found to promote condom use for the general client population, are irrelevant for clients who already have HIV [ 19 ].

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As our study found that HIV-positive clients who are receiving treatment and are already exposed to prevention services have high levels of HIV knowledge. In China, interventions for PLHIV focus on preventing secondary transmission within sero-discordant couples [ 67 ].

However, the qualitative highlight the role of an HIV-positive status and stigma against HIV in shaping sexual relationships and behaviors that may differ from the general client population. As described in the interviews, a positive HIV status motivated clients to seek extramarital and commercial sex to cope with sexual rejection from regular partners; find someone who could understand their experiences; and protect their families from HIV by meeting their sexual needs through others. Current interventions for PLHIV must address prevention in the context of extramarital relationships.

While the qualitative findings suggest that HIV-positive clients do not want to infect sex workers, interventions must bridge the gap between this intention and actual condom use practice. In addition, removing discrimination and stigma associated with HIV and sex work in society may also decrease unsafe sexual behavior.

All China female sex should be interpreted within the study limitations.

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Most participants were receiving ART treatment. Because those who receive treatment have had contact with HIV-related services, such as counseling, they are more likely to be knowledgeable about HIV. Thus, the population recruited in this study that received treatment would be representative of the larger HIV infected population in the country.

In addition, not only were there were several sensitive questions on sexual behaviors and buying sexual services on the study questionnaire, but when we conducted the study, there was also a campaign against sex work in China [ 25 ] and deliberately transmitting HIV to others is illegal [ 26 ]. This bias may be especially pronounced in the qualitative study because all interviews were recorded. Extensive measures were taken to protect participant privacy, to promote a trusting environment, and support anonymity of.

Trained researchers with experience working with this population conducted all data collection, with all personally identifiable information removed in order to reduce such biases. Additionally though, China female sex qualitative studies should aim to include more men who use condoms inconsistently to better understand the context of this behavior. Our sample could have been expanded to other study sites in order to increase the likelihood of identifying such individuals. Lastly, because of convenience sampling and the limited geographic range, this sample may not be representative of HIV positive CFSWs of China as a whole.

However, our study examines the sexual behaviors of a population that has rarely been studied in China. HIV-positive CFSWs continue to practice unsafe sexual behaviors with regular and irregular partners after an HIV diagnosis, but were more willing to protect their regular partners. Future interventions targeting HIV-positive CFSWs should not only be confined to sero-discordant couples, but also need to instill a sense of responsibility to protect commercial and casual partners and reduce the of concurrent partners.

The of this mix-methods study can be used to adapt current HIV prevention messaging to promote the agency of FSWs as partners and the importance of China female sex use when engaging in casual relationships. Scaling up prevention programmes to reduce the sexual transmission of HIV in China.

Int J Epidemiol. Understanding the diversity of male clients of sex workers in China and the implications for HIV prevention programmes. Glob Public Health. Article Google Scholar. J Acquir Immune Defic Syndr. Charlebois, et al. PLoS One. Heterosexual transmission of HIV and related risk factors among serodiscordant couples in Henan province, China. China Med J Engl.

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China female sex

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Female sex workers in China: vectors of disease?