Concurrent sexual relationship among male clients of female sex workers in China

1. Concurrent sexual relationship among male clients of female sex workers in China Presenters: Shan Qiao, Chen Zhang, Xiaoming Li, Yuejiao Zhou

2. Backgrounds • Male clients of sex workers have been overlooked in China’s HIV prevention efforts. • Existing literatures documented that the high prevalence of HIV among FSWs’ clients: ranging from 6-23% based upon different methodologies. • Clients had different risk levels for STIs/HIV based upon their socio-economic diversity (e.g., low-tier to high-tier ) • Diverse motivations and risk perceptions

3. Theories About Clients of FSWs Bridging population from high-risk group (e.g., FSWs) to general population (e.g., non-commercial sexual partners).

4. Theories About Clients of FSWs High-risk clients are considered as the main source of STI/HIV transmission in the HIV epidemic

5. Concurrent Relationship • Double standard on male and female sexuality • Clients’ perception of the relationship between commercial and non-commercial sexual partnership • Existing studies revealed the high rate of concurrent relationship among clients (e.g., Huang et al., 2012)

6. Clients of Low-tier FSWs in China

7. Hypotheses of the Current Study • Practice and motivation toward commercial sex among a sample of clients recruited from low-tier venues • Correlates of their concurrent partnerships • Prevalence of HIV, Syphilis and HCV among the sample

8. Methods • The data were collected in 2011 from P County, China • One hundred and three male clients were included in a cross-sectional survey with a self-administered questionnaire. • Collected information included their demographics, concurrent status, and HIV risk behaviors. Clients provided blood samples to test their HIV, Hepatitis C virus (HCV) and syphilis infection.

9. Result • Clients’ median age was 63 years with a range from 27 to 90 • Majority of them are Han-ethnicity (84.5%) and worked as farmers (93.2%) with less than middle school education (74.8%) • Of the total sample, 85.7% of the clients paid less than 20 yuan (approximately three USD) per service from FSWs • 92.9% of them reported inconsistent condom use in the last sex act with commercial sex partners Clients of low-tier FSW

10. Results • The prevalence of HIV, HCV and syphilis among the current sample was 1.9%, 1.0% and 19.4%, respectively. • Of the total sample, 53.4% concurrently had sex with noncommercial partners.

11. Results • Clients who wanted to “kill boredom” (aOR=6.27, 95%CI=1.07, 36.82) and who thought “seeking FSWs was popular” (aOR=7.22, 95%CI=1.61, 32.30) were significantly associated with the clients having concurrent sexual partners. • In addition, HIV knowledge and positive psychological effects on having sex with FSWs were all positively associated with concurrent partners among clients.

12. Discussion • A high rate of concurrent relationship among the clients recruited from the low-tier venues, which calls for immediate action • Social norms regarding the masculinity play a key role in their concurrent relationship • Consistent with existing studies regarding the specific characteristics of clients of low-tier FSWs

13. Limitations • Under-representative for clients who visit the high-tier venues • Self-selection bias and self-reporting bias • Limited generalization to larger client populations in China

14. Implications • Interventions need to address unequal power dynamics between male clients and FSWs as well as their non-commercial partners • Clients at different levels have different demands regarding HIV/STD prevention programs • Empowerment-based intervention among women in both commercial and non-commercial relationships