HIV Infection And Risk Factors In Female Sex Workers In Kaiyuan City, Yunnan Province

Background Female sex workers (FSW) in China are a population vulnerable to high risks of HIV and other sexually transmitted infections (STIs) due to their illegal status and strong social stigma. In areas of high HIV prevalence such as Honghe Prefecture in Yunnan Province, the FSW population links the transmission of HIV and other STIs with injecting drug use and commercial sex, which contributes to the spread of the epidemic across diverse population pools.The epidemiology of HIV and STI infections in FSW are therefore important for the prevention and control of HIV, in areas with developed commercial sex industries as well as other more generalized settings. Understanding the risk behavior of HIV positive FSW is a key element in designing effective policies for curtailing secondary transmission to others.Objectives (1) To investigate the HIV-1incidence and prevalence among FSW in Kaiyuan City, Yunnan Province, and to evaluate HIV related risk factors such as injection drug use, STI and unprotected sex.(2) To investigate changes in drug use and high-risk sex among FSW in an area with high drug use prevalence.(3) To investigate the changes in high-risk behavior of HIV-positive FSW who are aware of their status.Methods (1) Twelve serial, biannual cross-sectional surveys were conducted among FSW in Kaiyuan between2006to2012. Around600-800FSW were invited to join in each survey. Survey content included basic social-demography information, drug use, medical history, sexual activities, mobility, and HIV and STI related knowledge.(2) A cohort study on drug use and sexual activities was conducted among FSW for12months, with baseline,6month, and12month follow-ups. Information collected includes basic social-demographic information, health status, drug use, HIV/STI knowledge, and related risk factors.(3) A cohort study on HIV positive FSW was conducted for12months, with baseline,3,6,9, and12month follow-ups.Results (1) The12cross-sectional surveys included2997FSW, with HIV prevalences of10.3-21.6%and new infection rates of1.2-10.3%; the reduction in new infections over time was found by trend tests to be statistically significant. In the open cohort study,28new HIV infections were found, with HIV incidence0.2-1.1%. The incidence density was1.184/100person years (95%CI:0.746-1.623/100person year). Significant risk factors for HIV infection include history of drug use (AOR=8.83,95%CI:6.63-11.75),3or more clients in the past week (AOR=1.58,95%CI:1.20-2.10), and low fee per service (AOR=1.43,95%CI:1.08-1.89). In the open cohort study, the main risk factors were registered residency in Kaiyuan City (OR=8.5,95%CI:1.1-66.0), staying in Kaiyuan for five or more years (OR=3.1,95%CI:1.5-6.5), working at4or more sites during the past year (OR=3.2,95%CI:1.3-7.9), and drug use (OR=4.9,95%CI:2.3-10.6).(2)316FSW were surveyed in the prospective cohort study. During the one year follow-up, the population was highly mobile, but mainly traveled within Yunnan Province, with50%of subjects having left Kaiyuan in the past three months, and49%arriving at Kaiyuan from elsewhere.17%of FSW indicated drug use, mainly among older subjects with registered residency in Kaiyuan. FSW engaged in high-risk sexual activities, especially with regular partners. The proportion of FSW with4or more clients during the past week rose by11%(from45%at baseline to56%at6month follow-up). The proportion of insistent condom use with clients during the past week rose by7%(from87%to94%), while the proportion of insistent condom use with regular partner rose by15%(from21%to36%). The proportion of injecting drug use during past three months rose by34%(from21.6%baseline to56.3%at12month follow-up). The proportion of methadone maintenance treatment rose by11%(from26.4%at baseline to37.5%).(3)99HIV positive FSW were included in the prospective cohort study. They were mainly older in age (mean:34years old), married or cohabitating with a partner (60%), and used drugs (83%).51.5%conducted sex work in beauty salons, and11%in roadside shops or through street-walking.35%had11clients or more in the past month, and29%had fee per service at less than50RMB. After obtaining knowledge of their HIV positive status,45-59%continued commercial sex work. The proportion with10clients or more in the past month rose by10%(from17.5%in baseline to28%). Insistent condom use with clients in the past month remained high at95-96%, but condom use with regular partners was only59-70%.83%were drug users, with the majority (88-97%) doing so by injection. The proportion of methadone maintenance participation was low (35-55%). The proportion of free ART was also low (20-30%) in this population.Conclusion (1) FSW who use drugs and who work at low fee sites are a key sub-population for HIV prevention and control in Kaiyuan.(2) Greater efforts on promoting condom use in FSW should be placed on using with their regular partners rather than only with clients. As well, reduction of drug use among FSW should also be reinforced.(3) Nearly60%of HIV positive FSW continued commercial sex work at low fee sites. This points to a need for policies and laws that reduce the commercial sex activities of HIV positive FSW, including various forms of support and regulations against continued sex work.