In China, Negative Attitudes Toward HIV-Infected People Are Associated with Risky Sexual Behavior
In China, migrants who hold stigmatizing beliefs about HIV-infected people have higher levels of sexual risk behaviors and lower levels of protective behaviors than other migrants.1 In a cross-sectional survey among sexually experienced young adults who had migrated from rural to urban areas, some 65% of respondents believed that HIV-infected people should be ostracized, forced out of their villages, distanced as friends, or deprived of educational or employment rights. Compared with other migrants, these migrants were more likely to have had an STI, multiple sex partners or commercial sex partners, and they were less likely to use condoms or to accept an HIV test.
In 2002, researchers gave anonymous, self-administered questionnaires to migrants aged 18–30 working in the cities of Beijing and Nanjing. Respondents rated their agreement with four statements pertaining to stigma against HIV-infected people: "HIV-infected people should be ostracized by their spouse and family members," "HIV-infected people should be forced to leave their villages," "I would not be able to maintain a normal relationship with my friends if they became infected with HIV" and "HIV-infected people should not have the same rights to education and employment as others." Respondents provided information about their migratory history; this information was converted to a mobility index (number of migratory cities divided by years of total migration), with a higher index indicating a higher level of mobility. They also answered questions testing their knowledge of HIV, with higher scores on a scale of 0–22 indicating greater knowledge, and questions about their risk and protective behaviors. Analyses were restricted to sexually experienced respondents.
Of the 2,153 migrants included in the study, slightly more than half were recruited from Nanjing. Their average age was about 25, and one-third were women. Nearly all were of Han ethnicity (97%) and had at least a middle school education (93%). Somewhat more than half (56%) were single. Half had been migrating for five or more years, and the majority (71%) had worked in at least two cities.
Overall, 65% of migrants agreed or strongly agreed with at least one of the four statements indicating stigma against people with HIV. More specifically, 24% agreed or strongly agreed with one statement, 21% with two, 12% with three and 8% with all four. Migrants who held stigmatizing beliefs had lower scores for HIV knowledge than those who did not hold any such beliefs (13.8 vs. 15.3).
In bivariate analyses, migrants with a high school education or a postsecondary school education had lower odds of holding any stigmatizing beliefs than did those with only a primary school education (odds ratios, 0.5 and 0.3, respectively). The odds were also reduced among migrants who had a monthly income greater than US$57 (0.6–0.7). In contrast, the odds of holding stigmatizing beliefs were higher among migrants who had a mobility index of 0.71–1.00 than among those who had an index of 0.06–0.30 (1.4). In addition, migrants who believed that it was highly likely that they would become infected with HIV had sharply higher odds than did those who believed that it was impossible (3.1).
The questions on sexual risk behaviors revealed that 7% of migrants had bought or sold sex in the past month, 10% had ever bought or sold sex and 13% had ever been told by a clinician that they had an STI. In terms of protective behaviors, 38% of migrants used condoms at least some of the time when they had sex, and 57% were willing to take an HIV test.
In an unadjusted model, compared with migrants who did not have any stigmatizing beliefs about HIV-infected people, those who did had elevated odds of having had an STI (odds ratio, 2.3), having had multiple sex partners in the past month (1.8) and having ever bought or sold sex (1.9). On the other hand, migrants who endorsed stigmatizing beliefs had lower odds of using condoms at least some of the time (0.6) and of being willing to take an HIV test (0.6).
The patterns were similar in a multiple logistic regression model that took the migrants' social, demographic and economic characteristics into account. Compared with migrants who did not hold any such beliefs, those who held 1–4 of them had roughly doubled odds of having had an STI (odds ratios, 1.7–2.0). Similarly, compared with migrants who held no stigmatizing beliefs, those who held 2–4 such beliefs were more likely to have ever had a commercial sex partner (1.7–2.0), and those who had 3–4 such beliefs were more likely to have had multiple sex partners in the past month (2.0). In contrast, migrants who held one or 3–4 stigmatizing beliefs had lower odds of using condoms than did those who held none (0.7 for each). Migrants who endorsed two or 3–4 of the beliefs were less likely to be willing to take an HIV test than those who endorsed none (0.5–0.6).
The observed association between stigmatizing beliefs and risky behaviors among Chinese migrants, the researchers assert, may reflect an attempt to reconcile the conflict they experience when they engage in behaviors that they know are unsafe and socially unacceptable. For example, the researchers write, individuals may seek to justify their risky behavior by blaming people with HIV while assuming that they themselves are not at risk, or they may endorse mainstream beliefs in an effort to blend in with others who do not engage in risky behaviors. The finding that a person's stigmatizing belief "is a potential barrier to HIV-related preventive practices highlights the difficulties and challenges in implementing behavioral interventions," the researchers conclude.—S. London
1. Liu H et al., Relation of sexual risks and prevention practices with individuals' stigmatising beliefs towards HIV infected individuals: an exploratory study, Sexually Transmitted Infections, 2005, 81(6):511–516.