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 Clients FSWs General population (e.g., Non-commercial partners) Bridging population from high-risk group (e.g., FSWs) to general population (e.g., non-commercial sexual partners).

4. High-risk clients are considered as the main source of STI/HIV transmission in the HIV epidemic THEORIES ABOUT CLIENTS OF FSWS High-risk Clients (e.g., infected individuals, IDUs) FSWs Clients in general

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 Believing low chance of getting STD from FSW Misconception on easy cures on STD Misconception on how to detect STD before sex with FSW Low risk perception and prevalent misconceptions They have to face many other risks in life, and health is the lower priority They pursue immediate pleasures as they believe that condom use diminishes the sexual pleasures Less concern on health Lower SES (e.g., less educated, low-profile work) Other risk factors (e.g., drug users) Older age Personal characteristics

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 of low-tier FSW  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

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