Kathleen H. Reilly, MPH 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention Rome, Italy July 18, 2011

Yunnan, Henan, Guangxi, Xinjiang, Guangdong and Sichuan Provinces account for 81% of all HIV cases in China HIV & AIDS in China. Accessed June 23, 2011

 Sex work is associated with the spread of STIs and HIV  In China, approximately 1% of FSWs are HIV positive  Spread of HIV from urban to rural areas is attributed to sex work  Drug use may compound the risk of HIV infection

 FSWs are a vulnerable group for HIV infection  FSWs can act as a bridge of HIV infection to the general population  FSWs may have steady boyfriends  Clients may be married or may have multiple sexual partners

 Sex work is illegal, but widespread (estimated million sex workers in China)  Barriers to reaching FSWs are stigma, economics, politics, and decentralized Chinese system  Mobility: many FSWs migrate within China and are difficult to follow

 Chinese government is currently engaged in a crackdown on sex work  FSWs have conducted work in a ‘don’t ask don’t tell’ environment, the crackdown has influenced some to change locations  As sex work is driven underground it is more difficult for public health workers to locate and offer services and interventions to FSWs

 The government is hesitant to create policies which appear to approve of sex work  Clients can be considered to have more economic power in the relationship  Lack of evaluation research regarding HIV intervention programs in China

 Street  Massage parlors  Hair salons  Karaoke bars  Truck stops  Brothels  Escorts

 High-end sex workers are often difficult to reach  Other types of sex workers may be difficult to reach  Students  Factory workers

 STI clinics  FSWs may experience stigma from visiting a clinic exclusively for STIs  Clinics should be located in areas convenient to access and where FSWs would feel comfortable  Periodic outreach testing could be arranged for large sex work venues

 Key stakeholders  Important to get buy-in from key stakeholders  public security  local agencies  venue owners (karaoke bars)  Public security can be an asset to a program instead of a threat

 Sex work bosses  Typically do not migrate as much as FSWs  Often responsible for FSWs’ health  Can mandate FSWs to use condoms in commercial sex transactions  Can influence FSWs to get tested for HIV and STIs

 Offering affordable testing and treatment  Budget limitations  Current standard is blood drawn ELISA with 2-4 week turnaround  Rapid tests have not been approved as a standard of care by the Chinese government  Feasibility studies are being conducted on using rapid tests among MSM in Beijing  Rapid tests are comparatively more expensive

 Some countries have banned sex work  This may drive sex work underground, making safe sex promotion, treatment and monitoring more difficult  Many countries promote “harm reduction” strategies to encourage condom use and regular testing

 Who are clients?  How do you reach clients?  Limited number of Chinese studies on commercial sex clients  Most studies use convenience sampling  Low- income clients are more likely to participate in studies  Interventions should promote positive attitudes towards condom use among clients

 The majority of interventions target FSWs, but there are other types of commercial sex workers to consider  Males selling to males  Males selling to females

 Like FSWs, MSWs also face stigma and discrimination  Intervention outreach methods will likely be quite different from interventions designed for FSWs  Venues may be different  More discreet locations such as parks, public bathrooms

 Stigma could be reduced by creating programs that include the general population  Decrease marginalization of sex work as an industry  Increase the familiarity and comfort with communicating about culturally difficult issues