Abstract

China is the world’s most populous country, and yet relatively little is known about the acquired immunodeficiency syndrome (AIDS) epidemic confronting that nation. The number of cases of human immunodeficiency virus (HIV)/AIDS in China is not known with any assurance, and few data are available about the level of HIV-related knowledge among the population. We analyzed data from a government-sponsored survey conducted in 2000 in seven Chinese counties. Our findings indicate that the general population aged between 15 and 49 years is very often uninformed about basic issues. The results suggest an immediate and urgent call for action in the form of widespread HIV prevention measures.

With the acquired immunodeficiency syndrome (AIDS) epidemic firmly entrenched in many countries throughout the world, there is still much to understand about the epidemiology of the disease in countries such as China, where AIDS is either a recent phenomenon or not too much record has been recorded. According to the Chinese Ministry of Health, from 1985 to the end of 2001, a total of 30,736 cases of AIDS or human immunodeficiency virus (HIV) infection (confirmed by testing) had been identified (1). Of these cases, 1594 were identified with full-blown AIDS, 684 of whom were reported to have died. These figures contrast sharply with the estimation that more than 850,000 individuals would be infected with HIV by the end of 2001 (1). This number still seems small when viewed against a total population of 1.276 billion. Regardless, the data indicate that HIV/AIDS has a firm foothold in China. Moreover, the Ministry of Health expects up to 10 million infections by 2010 if effective prevention measures are not immediately implemented (1). To gauge the understanding of HIV/AIDS among the general population in China, the Information, Education and Communication Department of the State Family Planning Commission conducted a survey to assess HIV-related knowledge, attitudes, perceptions, and selected reproductive practices of persons aged between 15 and 49 years in seven counties.

Previous studies

We are unaware of any earlier studies of HIV/AIDS-related knowledge, attitudes, and practices conducted among the general population of China. Selected populations have been studied, however, including Dai ethnic villagers in Yunnan province (2), health care workers (3), sexually transmitted diseases (STDs) clinic patients (4), young males in Southwest China (5), sex workers (6), and adolescents (7).

In a 1994 survey of Dai villagers, Liao and coworkers found that only 18% of respondents had heard of AIDS, only 25% had heard of STDs, and only 28% had heard of condoms (2). Among those who had heard of AIDS, STDs, and condoms, there was still little specific knowledge of disease transmission. In a survey of health professionals in 11 areas in China, 67.6% of health care workers correctly answered all three questions about HIV transmission routes and about half (49.5%) knew that blood is the most efficient route of transmission (3). Three percent knew about the need for universal precautions. Among patients attending an STDs clinic in Jinan, Shandong over a 6-month period in 1998, researchers found that respondents generally had little HIV knowledge, engaged in risky sexual behavior, and were unlikely to always use condoms (4).

A 1994 survey including young men from villages in Longchuan, Yunnan, found that over half (55%) of respondents incorrectly answered all questions about transmission and prevention (5). Risky behavior (injection drug use, sharing injection equipment, and lack of condom use) were also common. Knowledge about transmission of STD, including HIV, was also examined in a study of sex workers in Guangzhou Municipality (6). Among the women who were interviewed, counseled, and tested for STDs/HIV during 1998 and 1999, knowledge about STDs/HIV transmission and the use of condoms was low. Finally, in a study of students attending secondary schools in Hong Kong, 13.9% rated themselves as having much HIV/AIDS knowledge (7). Most of the students rarely or never discussed HIV/AIDS with their family (85%), teachers (80%), or friends (60%). Television was their primary source of information about HIV/AIDS.

These studies paint a discouraging picture, and suggest that in general much of the Chinese population know little about HIV/AIDS as well as how to prevent its spread. The information about the epidemiology of HIV infection in China must be added to this picture, although here the research is also limited. Yu and coworkers described the situation nationally for the period from 1985 to 1994 with data obtained from the Chinese Ministry of Public Health (8). At the end of 1994, only 1774 HIV positive or AIDS cases had been identified. Similar to the situation in the United States in the 1980s, most of the cases were among males under 39 years of age. Unlike the United States, however, most were reported drug users. Over two-thirds (68.1%) were farmers. More than 80% of cases were from Yunnan Province (and within Yunnan among Dai ethnic minorities), although there was evidence that the virus was beginning to emerge in urban areas (Beijing, Shanghai, Guangdong, and Fujian). By 1996, 30 out of 31 provinces, municipalities, and autonomous regions had reported cases of HIV infection (9).

A number of studies have examined behaviors related to the risk of HIV infection among selected populations in China. In 1997 and 1998, Zhang and colleagues surveyed 426 men who had sex with men (10). Risky sex was common: 93.4% engaged in orogenital intercourse, 63.6% in anogenital intercourse, 15.5% always in insertive anal intercourse, and 7.8% always in receptive anal intercourse. A median of 9 cumulative sex partners was reported and nearly two thirds never used condoms. Among the 302 men with information on STDs, 25.5% reported that they had contracted an STD. Almost half (48.4%) reported that they had engaged in sexual intercourse with women and one-third that they had been married. These findings suggest a very efficient way for HIV spreading, both to men and women in mainland China.

Lau and Thomas interviewed 1254 Hong Kong men aged between 18-60 years in 1997 upon their return from mainland China (11). Almost one third (32.3%) reported that they had sexual intercourse with one or more commercial sex workers (CSWs) in the previous 6 months while traveling in China, and 11.3% reported the same behavior during their most recent trip. Percentages were higher for younger and less educated men. Among those who reported sexual intercourse, about one-third not always used condoms, and almost 8% of all respondents said that they would not use a condom with a CSW in mainland China. Those who would not or did not use condoms with CSWs were less likely to use condoms with their wives or girlfriends. In addition, 20.1% of respondents reported that they had an STD. This combination of behaviors and STDs suggests a scenario for an increasing incidence of HIV infection in Hong Kong.

In their study of patients who visited an STD clinic in Jinan, Wang and colleagues found that most participants had multiple partners in the previous 12 months (87.1% of men; 54.0% of women), with a mean of 6.2 partners for men and 7.2 for women (12). Over two-thirds of men reported exchanging money for sex and 24% of women reported exchanging sex for money. None of the women and less than 5% of the men always used condoms with their spouses, boyfriend/girlfriend, or others, and over two-thirds of the men never used condoms with someone other than their spouse or girlfriend/boyfriend.

Three additional reports examined the prevalence (and in one case, the incidence) of HIV infection among other selected populations. A study of plasma/blood donors in rural eastern China found that 1043 (69%) of 1517 persons who were interviewed and tested for HIV had previously donated plasma (13). Overall, the prevalence of HIV infection was 8.9%, and it was significantly higher (12.5%) among plasma donors than among those who denied donating blood (1.3%). The prevalence of secondary transmission (among the donor’s non-donor spouses) was 2.1%. HIV infection was not associated with a recent history of invasive medical care, a history of drug use, or a history of multiple sex partners.

In a study of 318 heroin users in Pingxiang City (Guangxi Province) who were tested for HIV infection, Lai and coworkers found a prevalence of 15.4% at baseline (14). After a median follow-up of 8.1 months, the incidence of HIV was 2.38 per 100 person-years. During the second follow-up (median of 8.3 months) of 130 users, incidence increased to 6.86 per 100 person-years. The authors documented substantial needle sharing and a high incidence of hepatitis C Virus (HCV) infection among respondents, both of which may facilitate the transmission of HIV. Finally, in the study by van den Hoek and colleagues of sex workers in Guangzhou Municipality, the prevalence of HIV infection was low (1.4%), but the prevalence of other STDs was high (6). Only 30% of sex workers reported that they always used condoms with their clients.

While these results may not directly apply to the general population, they are certainly evidence of the presence of HIV infection in China, of a possibly increasing problem, and the potential for greater spread. It is therefore important to begin examining the level of HIV/AIDS knowledge among the general population so education and intervention can be appropriately targeted for this group. The purpose of this paper is to describe the HIV-related knowledge, attitudes, and other factors from our survey of Chinese residents in the seven counties. We expected to find a relatively low level of knowledge among the general population and a variation according to sociodemographic patterns.

Even before the Chinese government acknowledged in August 2001 that the country was facing a serious AIDS problem (1), the situation had reached a critical level. By 1996, all but one province had been touched by the epidemic (9). From 2000 to 2001, the number of new cases of HIV/AIDS increased 58% and the number of people estimated to be infected with HIV increased 30% (1). The potential for further spread is substantial and pathways to the general population are evident (6, 10-14).

Lack of knowledge on HIV/AIDS transmission and prevention

Similar to surveys of more selected populations (2-7), ours indicates an overall lack of knowledge about HIV/AIDS transmission and prevention among the general population of individuals between 15 and 49 years old in China. Although the majority of respondents had heard of AIDS and said that they knew that it can be transmitted and prevented, most did not know more specific information, such as the cause of the disease, how to detect it, the modes of transmission, or how to prevent it. Not surprisingly, the more educated and economically advantaged groups were better informed, but even within these groups, the level of knowledge about HIV/AIDS was only moderate.

The overall lack of knowledge about HIV suggests that the general public lacks a sense of risk about transmission and an awareness of self protection. Close to 17% of respondents had never heard of HIV. Of those who had, almost 6% said that they would do nothing if they suspected that they were infected with HIV and, surprisingly, close to 90% said that they would not avoid sexual intercourse. There was also a general reluctance among respondents to talk to anyone about AIDS. Indeed, about 40% said that they would avoid contact with HIV positive individuals and most respondents indicated that they would have little concern or sympathy for acquaintances who were infected. These attitudes only serve to promote stigma and discrimination and certainly increase the problems of those living with HIV or AIDS.

These findings are reminiscent of a 1996 survey of college students from one university in China (15). Most students said that they would feel sympathy for someone with AIDS, at the same time, they felt that those who had the disease should be separated from others (i.e., quarantined) and that persons with AIDS have the responsibility to be considerate of others by isolating themselves. Moreover, several students said that they would be less sympathetic towards someone with AIDS if the disease was contracted through homosexual activity, injection drug use, or promiscuous heterosexual sex, rather than if the person acquired the infection as a child or hemophiliac.

As part of an effort to educate the general population about AIDS, the survey findings suggest a major focus on the benefits of condom use. Respondents were asked about current contraceptive practices and whether they had ever used condoms. Only 5.5% of respondents said that they were currently using condoms for contraception and just over one quarter (28.4%) reported that they or their spouses had ever used condoms. However, we did find that experience with condoms was related to being more informed. Those who were currently using condoms and those who had ever used condoms were more likely to know that using condoms correctly can prevent HIV/AIDS. The reverse was also true. Those who were more knowledgeable about condoms were more likely to have used condoms. Increasing knowledge about condoms may help to increase condom usage which in turn, may help to prevent HIV transmission.

Respondents were further queried about their sources of HIV/AIDS information, that is, where they obtained current information and where they preferred to obtain information. In both instances, the majority obtained and had a preference for obtaining their HIV/AIDS information from TV, followed by books or newspapers and the radio. Only a small percent of respondents obtained or preferred to obtain their information from medical experts or family planning agencies. However, those who were more knowledgeable about HIV/AIDS were more likely to obtain their information from family planning agencies or medical experts, rather than from media sources. Increasing education about AIDS may help to ensure that the most informative avenues for information are utilized.

The future

Despite the relatively low levels of knowledge about HIV/AIDS, almost 84% of respondents said that it was necessary to teach HIV/AIDS prevention education in school and that middle school was the appropriate time for this type of instruction to be provided. School-based prevention education would certainly be one avenue to inform the general population of adolescents, particularly if they are reached before they become sexually active.

This apparently conflicting finding (low level of HIV knowledge and strong support for HIV/AIDS education in school) is difficult to explain, although social desirability (16) may contribute to the finding that a majority of respondents supported HIV/AIDS education in school. Also conflicting was the fact that over two-thirds (67.5%) of respondents recognized that AIDS could be transmitted through sexual intercourse, yet almost 90% said that they would not avoid sexual intercourse when asked what they would do if they suspected that they were infected. Again these responses are difficult to reconcile, but given the overall lack of knowledge about HIV/AIDS, it seems plausible that the relatively high prevalence of those who knew this particular route of transmission (sexual intercourse) may be less than reliable.

There are other limitations to our data that should be recognized. Although households were sampled to obtain at least 1000 respondents in each county, we have no information on those who refused to participate or those who could not be contacted at home. Therefore, we do not know whether these individuals systematically differed from those who participated, in which case our sample would not be representative. In addition, because our data were self-reported, we have to allow for both under and over reporting. Finally, since this is the first major HIV-related survey of the general population, additional work will need to be conducted to ensure the validity of these data. However, the relatively consistent pattern of our findings, coupled with the magnitude of many of our estimates (even with over reporting taken into account), suggests that there is little specific knowledge about HIV/AIDS among the general Chinese population.

Clearly, this lack of knowledge must be addressed, especially as the AIDS problem intensifies throughout the country. It is important that preferred sources of HIV/AIDS information are taken into account and examined closely. The national information and education campaigns should use these findings to correctly inform the public and potentially prevent new infections. Information about the role of condoms in preventing infection and easy access to condoms should be included in these educational efforts. The apparent public support for school-based education should also be considered in any national or provincial effort. In addition, negative attitudes towards persons with AIDS must be taken into account and policies should be implemented to prevent stigma and discrimination. The substantial and growing HIV/AIDS problem will not only affect China, but the rest of the world as well and it is in the interest of all to address it quickly and effectively. National and international cooperation in the fight against AIDS in China is urgently needed.

References and notes