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Abstract
Yunnan Province had the first HIV outbreak and is still the worst affected area in China. The changed social norms and increased migration since the economic reform in the 1980s have spawned increased HIV related risk behaviors such as drug use and commercial sex work. The large HIV infection pool among injection drug users (IDUs), as well as increased sex trade and migration, predict the potential of fast future HIV expansion.
The data were collected from a survey among at-risk populations in Dehong Prefecture of Yunnan in 2004. The analyses of 36,360 participants aged 15-44 years show that HIV-related risk behaviors (drug use, drug injection, needle sharing, commercial sex, condom use in commercial sex, and dual drug use and commercial sex behavior) were prevalent in persons of lower social status, including the unmarried and unemployed, as well as the Jingpo ethnic people. Drug users, especially IDUs, were associated with both providing or procuring commercial sex and a decrease in condom use. Persons reporting a prior HIV test were less likely to report HIV-related risk behaviors. Exposure to a condom distribution program was associated with increased condom use.
A structural equation modeling method was used to develop HIV causal models based on data from 42,690 participants aged 15 years and above. The results show that male and female models had the same contextual factors, including low education, minority ethnicity, farmer/unemployed, tourist area residency, and unmarried status. In both male and female models, these contextual factors had indirect effects on HIV infection which were mediated by drug injection and unprotected commercial sex, behaviors. In the male model, drug injection was predicted by unprotected commercial sex but drug users were less likely to engage in unprotected commercial sex; in addition, the effect of unprotected commercial sex was mediated by sexually transmitted disease history.
We suggest future HIV interventions target changing both drug injection and commercial sex behaviors and further expanding HIV voluntary counseling tests and condom promotion programs into risk populations, especially those of low social status and hard to reach.
