Epidemiologycal Study On Hiv/Aids Of Female Sex Workers And Their Male Clients In A Chinese-vietnamese Border Region

BackgroundHeterosexual transmission is recognized to be the primary mode of recent human immunodeficiency virus(HIV)/acquired immune deficiency syndrome(AIDS)epidemic in China.FSWs and their male clients are not only high-risk groups for HIV infection,but also play a role as bridge for HIV transmission to the general population.The relationship of HIV associated factors between FSWs and male clients,in addition the research data of influence on regional HIV epidemics by FSWs and male clients are exiguous in Chinese-Vietnamese border region of Yunnan province,China.ObjectiveTo estimate the prevalence and trend of HIV infection among Vietnamese FSWs,Chinese FSWs of Yunnan province,and male clients during 2006 to 2015.To estimate the prevalence and trend of HIV infection among FSWs and male clients in Hekou county.To analysis associated factors of HIV infection among FSWs and male clients.To evaluate the influence on regional HIV epidemics by FSWs and male clients.In addition,to provide references for HIV intervention and future research targeting FSWs and male clients in Chinese-Vietnamese border region.MethodsChinese(from database of Wan Fang,Wei Pu,and CNKI)and English(from database of Web of Science,PubMed,and ScienceDirect)peer-reviewed articles published between January 2006 and December 2015 were systematically searched.Meta-analysis were used to calculate the pooled prevalence and trend of HIV infection.Four-stage serial cross-sectional surveys were carried out every 6 month among FSWs and male clients between June 2014 and November 2015 in Hekou county,Yunnan province.Information of social-demographic characteristics,mobility,reproductive and health seeking behavior,sexual and drug using behavior were collected through questionnaire interview.Blood samples were collected to test for HIV,herpes simplex virus-2(HSV-2)and syphilis,urine specimens were collected to test for morphine,ketamine and amphetamine-type stimulant.Logistic generalized estimating equations model and cumulative odds logit model were used to determine the factors associated with HIV/STIs infection prevalence.Geo-information system was used to depict the spatial distribution map of FSWs and male clients.Exhaustive CHAID model and Web graph were used to determine the relationship of associated factors of HIV/STIs prevalence.Spectrum/EPP was used to calculate the PAR% of HIV epidemics in Hekou county correlated with FSWs and male clients.Results1.Systematic review and Meta-analysis: Finally 13 articles 31 records of Vietnamese FSWs,47 articles 95 records of Chinese FSWs of Yunnan province,and 32 articles 39 records of Chinese male clients were included in the quantitative synthesis.The prevalence of HIV infection of Vietnamese FSWs was estimated as 4.26%(95%CI:3.04~5.65%).The HIV prevalence of Chinese FSWs and male clients were 2.65%(95%CI:2.54~2.78%)and 1.41%(95%CI:1.10~1.76%).The HIV prevalence of Vietnamese FSWs and male clients have been raised in the first several years,than continuous decline during 2006 to 2015.In addition,it showed a downward trend of HIV prevalence of Chinese FSWs in the period 2006-2015.2.Vietnamese FSWs: Most of our Vietnamese female respondents come from North provinces of Vietnam adjoin Hekou county.Totally 1036 Vietnamese FSWs participated in the HIV test,of whom the HIV prevalence was 2.12%(22/1036).The trend of HIV prevalence of Vietnamese FSWs was not significantly during the serial cross-sectional surveys.Analyzed with multivariate logistic regression,the factors associated with HIV infection were HSV-2 infection(OR=3.83,95%CI: 1.37~10.76),unqualified knowledge of HIV(OR=10.40,95%CI: 3.77~28.66),use condom with male clients sometimes(OR=5.82,95%CI: 1.44~23.59),has accepted HIV intervention(OR=0.27,95%CI: 0.08~0.84).Analyzed with cumulative odds logit model,the factors associated with one or more STIs infection were minority(OR=0.64,95%CI: 0.49~0.83),rent self to male clients(OR=1.50,95%CI: 1.00~2.24),and had sexual behavior with IDUs(OR=5.20,95%CI: 2.05~13.20).CHAID model confirmed HIV related knowledge was the most powerful factor associated with HIV infection of Vietnamese FSWs.Furthermore Web graph showed that kidnapped experience had the most closely relationship with HIV infection.3.Chinese FSWs: except for a few respondents,most of Chinese FSWs have the household registration of Honghe district,Yunnan province.The number of Chinese female participants declined significantly during the serial cross-sectional surveys.Totally 216 Chinese FSWs screened for HIV and only 1 of them was HIV positive.The HIV infected Chinese FSW engaged in commercial sex work less than one month,so that basically eliminating HIV infection through commercial sexual behavior.4.Male clients: The source of most male clients of FSWs were cities or counties from Yunnan province that close to Hekou county.Totally 776 male clients participated in the HIV test,of whom the HIV prevalence was 2.06%(16/776).The trend of HIV prevalence of male clients was not significantly during the serial cross-sectional surveys.Analyzed with multivariate logistic regression,the factors associated with HIV infection were.Age ?50 years(OR=8.11,95%CI:1.26~52.16)and morphine positive(OR=7.35,95%CI:1.42~38.06).Analyzed with cumulative odds logit model,the factors associated with one or more STIs infection were marriage(married or cohabiting: OR=2.43,95%CI: 1.06~5.56;divorced or widowered: OR=4.86,95%CI: 1.82~12.93),age(40~: OR=2.22,95%CI: 1.17~4.22;50~: OR=2.65,95%CI: 1.30~5.37),and preference of commercial sexual partners(others: OR=3.99,95%CI: 1.87~8.50).CHAID model confirmed age ?50 years was the most powerful factor associated with HIV infection of Vietnamese FSWs.Furthermore Web graph showed that morphine positive had the most closely relationship with HIV infection.5.Comparative research and PAR% estimation: Comparing the three groups,there was a significant difference of income of commercial sexual services and monthly account of male clients between Vietnamese FSWs and Chinese FSWs.The HIV PAR% of Vietnamese FSWs for women aged ?16 years in Hekou county was estimated as 2.97%,the probability of HIV monthly incidence of at least one male client infected by Vietnamese FSWs was 23.12%.The HIV PAR% of male clients for men aged ?16 years in Hekou county was estimated as 0.68%~6.41%,the probability of HIV monthly incidence of at least one FSW infected by male clients was 0.85%~4.27%.Conclusions1.The results if systematic review and Meta-analysis indicated the HIV prevalence declined after the year of 2012 and Vietnamese FSWs had the highest HIV prevalence of the three groups.Subgroup analyses confirmed that FSWs and male clients from southwest China have higher risk of HIV infection than other regions.2.The HIV prevalence in the Vietnamese FSWs in Hekou county was lower than the estimate of previous studies.However due to the high mobility and commercial sexual partner exchanges,Vietnamese FSWs still play an important role in HIV epidemic in the Chinese-Vietnamese border region.For most Vietnamese female respondents,lack of related knowledge and identification of infection risk of HIV may be the major risk factor associated with HIV infection.3.For Chinese FSWs in Hekou county,the HIV prevalence has no significant change compared with previous reports.In addition,the HIV prevalence of Chinese FSWs was lower than the estimates of similar population in other regions in Yunnan province.Most Chinese FSWs in Hekou county are entertainment waitress part-time engaging in sex work,not full-time commercial sex worker.4.Compared with past studies,the HIV prevalence declined and the condom usage rate of commercial sexual behavior raised among male clients of FSWs.Older male clients need focus on in future HIV prevention.The HIV prevalence of male clients in Hekou county influenced by the combined effect of illegal drug use and commercial sexual behavior.5.Commercial sexual service charge and related behaviors between Chinese FSWs and Vietnamese FSWs were significantly different.It indicated the two groups may come from completely different populations.It is lack of evidence to confirm male clients playing a role as bridge in HIV transmission between Chinese FSWs and Vietnamese FSWs in Hekou county.The relatively low HIV PAR% of FSWs and male clients indicated the HIV epidemic among local population not mainly attribute to FSWs and male clients in Hekou county.HIV molecular epidemiology and molecular network research may be considered in future research in order to explore the relationship of FSWs and male clients in HIV transmission.