This is one of the first studies that measures cervical cancer and HPV- related knowledge, awareness, and behaviors among FSW in China. Our data revealed that FSW in China had low levels of knowledge of cervical cancer, HPV, and the HPV vaccine. Few FSW perceived themselves at risk for cervical cancer despite their high exposure to multiple sex partners and high rates of unprotected sex. Only a small portion of FSW ever had a Pap smear, but many were willing to take the HPV vaccine. The level of cervical cancer- and HPV-related knowledge among FSW was lower than that of FSW in other countries, such as Thailand and Peru [25, 26]. as well as general urban Chinese women . For example, a recent study among Peruvian FSW showed that 69.0% of participants were aware of the transmission route of HPV, compared to 26.3% in the current study . Another study conducted in Thailand revealed that more than half of FSW knew the possible consequences of HPV infection, but less than one third of FSW in the current study were aware of them .
Our data provide useful information for further research and policy making. As China’s cancer burden continues to grow, more attention has been directed toward effective prevention programs . Overall cervical cancer mortality has been declining, but the declining trends showed only for older women; younger women showed an increasing trend . Given the large population and limited resources in most areas of China, identifying the most at-risk populations and designing targeted prevention interventions are most efficient.
To date, no national cancer prevention program is available in China despite several national and international efforts working towards this goal [33, 34]. Most urban women have access to cancer screening through their employer-sponsored health insurance, but rural women have had access to free cervical cancer screening under a government-sponsored program only since 2009 . The majority of FSW in China are rural-to-urban migrants and not covered by any health insurance; furthermore, the stigma against commercial sex has placed them in “double jeopardy” . In a study to examine barriers to HIV testing, Hong and colleagues found that perceived stigma and denial of risk were the major reasons for not seeking testing . The literature documents very high rates of HPV infection in FSW, including recent data from China showing an HPV prevalence of 39% in FSW [11, 16–19, 29, 32, 37], which stands in sharp contrast to the very low level of awareness, knowledge, and perceived risk of cervical cancer in FSW in China. As demonstrated in the current study, only 15% of FSW in China ever had a Pap smear compared to 70% of their counterparts in Thailand . We therefore call for policies and programs to promote cervical cancer awareness and screening in this population in China.
Empirical studies, including the ones conducted in China, showed that early screening can efficiently reduce cervical cancer mortality [23, 24]. Several model-based cost-effectiveness analyses suggested that HPV DNA screening plus HPV vaccine in certain high-risk population is the most effective approach to control cervical cancer . FSW are at high risk for cervical cancer, yet they are highly mobile and severely stigmatized; thus, prevention efforts to reduce cervical cancer morbidity and mortality in this population deserve thoughtful planning and implementation. First, given the HPV vaccine is designed to be prophylactic, it is most effective for young women without previous or current infection with vaccine-related HPV genotypes . However, the already-high HPV prevalence among FSW prevents the vaccine from being effective among this population. Therefore, it merits further research to explore the feasibility of vaccinating young women, especially rural women. Second, as a positive HPV test (especially HPV DNA screening) will only tell the provider that a FSW is HPV infected but not necessarily that she has cervical dysplasia , we thus recommend that a positive HPV test for a FSW should be used as a proxy for cervical abnormality and a cytology examination needs to be performed on the HPV-positives. Third, our data indicated that ever had HIV testing was the most significant predictor of a Pap smear (aOR = 11). China has established a comprehensive HIV voluntary counseling and testing (VCT) program, and the service has been scaled up to more than 6,000 clinics among all provinces nationwide [39, 40]. We thus suggest that cervical cancer screening and counseling be integrated into the existing VCT practice for women. Finally, FSW constitute a highly heterogeneous population, and their risk behaviors vary considerably across age groups and working venues; any prevention intervention programs must be tailored to the subgroups to improve efficacy.
Our study has several limitations. First, our survey was based on a closed-ended questionnaire; open-ended questions might have gauged better cervical cancer-and HPV-related awareness and perceptions, especially when no prior data were available from this population. Second, our study was based on a cross-sectional survey, and the correlation observed in our data could not be interpreted as a causal relationship. Finally, our sample was a convenience community sample which may limit our ability to generalize the findings to FSW populations in other areas of China.