Unmarried male migrants and sexual risk behavior: a cross-sectional study in Shanghai, China

It is clear that China is facing a frightening epidemic of AIDS. By 2011, the official estimate of the total number of people infected with HIV was 650,000 [1]. Although the epidemic remains has been largely confined to high-risk groups, the virus has begun to spread to an increasing number of areas and populations, resulting in the early phase of a likely the widespread dissemination of HIV to the general population [2]. At the same time, the mode of HIV transmission has shifted substantially over time. Sexual transmission has been the largest single cause of HIV infection in China, and heterosexual transmission has already become the main mode of transmission [1]. Rural-to-urban migration may be playing a crucial role in the rapid diffusion of HIV [3].

With China’s fast industrialization and urbanization since the initiation of the “open door policy” in the 1970s, China has experienced rapid economic growth. Large economic disparities between urban and rural areas led to the emergence of rural-to-urban migration as villagers looked for new jobs, higher income and homes in towns and cities. There were an estimated 230 million migrant laborers in China by the end of 2011 [4].

Nearly half of China’s migrants were born in the 1980s, their average age being about 28 years old [4]. The majority of migrants have a poor educational background. Although most are in the sexually active stage of their lives, they actually possess little knowledge about HIV, sex health-related matters, or protection, and have almost no access to preventive education or regular health care. This all leads to a major concern about the health consequences of migration in China today: migrant workers are particularly vulnerable to sexual risk behavior, which in turn makes them more susceptible to HIV infection [2, 5, 6].

Most young migrants are rural-to-urban migrants, far from home and released from the restraints exerted by their parents; they are living in single-sex dormitory housing and working long hours in difficult conditions; and their attitudes about sexuality and lifestyles have changed since they immigrated [2, 5]. It is assumed that under such circumstances, these migrants are more likely to engage in sexual risk behavior, like having casual sex and paying for sex and having multiple sexual partners [7–9]. Some studies have shown that migrant workers’ knowledge of HIV/AIDS is minimal and that they are unable to obtain useful information, consultation, and healthcare services pertaining to HIV/AIDS [10, 11]. Some researchers have found a relationship between sexual risk behavior and poor knowledge of HIV/AIDS. Sexual behavior studies in China and other countries have shown that poor knowledge of HIV/AIDS increases the likelihood of engaging in sexual risk behavior [12, 13]. Studies from other countries have shown that the sexual attitudes of young, mobile people become increasingly open and that they are particularly likely to indulge in HIV/AIDS-related sexual risk behavior [14–17]. Similar studies of migrant workers in China have indicated that premarital and extramarital sex appear to have become more accepted among young people [18, 19]. Hesketh [20] proposed that traditional attitudes to sexual relationships place migrant workers at low risk for engaging in casual sex. Na He [21] stated demand for legalization of commercial sex increases the risk of having more than one sexual partner. Xun Zhuang [22] concluded that acceptance of multiple sex partners increases the risk of engaging in sexual risk behavior. In addition, the household registration system (the hukou) has restricted peasant entry into the cities to control unwanted migration out of the countryside. Therefore, most rural-to-urban migrants can only gain temporary status in the cities and have to travel back to the countryside periodically. Several studies have shown that migrants tend to be at a higher risk of contracting HIV and other sexually transmitted diseases (STDs) than non-migrants [23, 24]. A great many studies have indicated that HIV infected patients in China cities consist mostly of migrant workers [25–27]. Multiple sources have documented how migrants serve as a bridge population for the spread of HIV from migrant destinations back to native regions, with the frequent seasonal shifts between work in cities and return to homelands leading to the further transmission of HIV among their sex partners [28–30].

Previous investigations of migrants’ HIV-related sexual behavior in China have largely focused on male migrants or migrant female sex workers [21, 22, 31]. Few studies have focused on sexual risk behavior in rural-to-urban unmarried male migrants. Unmarried males in particular may be likely to engage in HIV risk-taking behavior, much more so than married males because of their specific physiological and psychological characteristics in the context of exposure to HIV risk-taking factors in the urban environment [2, 32]. For this study, therefore, we conducted a community-based, cross-sectional study of HIV-related risk behavior among unmarried male migrants in Shanghai, China’s largest city with almost nine million migrants [33]. The objectives of the investigation were to describe the HIV/AIDS-related knowledge, attitudes, and risk behavior of and thus identify possible sexual risk behavior factors among unmarried male migrants in Shanghai.

To our knowledge, this study is the first in China to document sexual risk behavior and attempt to assess the likely causal factors for sexual risk behavior among unmarried male migrants.

We found a high proportion of male migrants having sexual intercourse before marriage, which may still represent an underreporting due to the sensitive nature of the issue and strong social and cultural taboos related to this area in China [35]. At the same time, the prevalence of sexual risk behavior (defined as sex with a non-regular sex partner) among single men revealed by this data is much higher than the levels observed by Xun Zhuang et al [22]. This may be because the latter study was based on the general population rather than focusing on an unmarried group. In addition, among young unmarried men interviewed in this survey, the rate of sexual risk behavior increased significantly with age. This means older respondents were more likely than younger ones to have non-regular sexual relationships. One of the main reasons could be that sexually active unmarried men in general engaged in sexual risk behavior in order to meet physical needs and relieve their loneliness and anxieties about home [2].

Of the participants engaging in premarital sex in our sample, 36.3% reported having had more than one sexual partner in their life, a proportion significantly higher than that reported by another study [21]. This finding is important because it enhances our understanding of the possible effects of multiple sex partners as increasing the likelihood of rapid transmission of HIV/AIDS. If someone has acquired HIV/AIDS, he may infect other partners, so not only are a large proportion of unmarried men at high risk of infections (those with multiple sex partners), but their partners are also likely to be at risk [36].

The study also showed that only about 43.0% of all migrants believed that use of condoms could prevent HIV/AIDS, and infrequent condom use, another high-sexual risk behavior, was common among the males who had had sex in the six months before the study period. Nearly three-quarters (73.7%) of respondents did not use a condom. More importantly, condom use was also quite low among the migrants who engaged in sexual risk behavior. A considerable proportion (66.1%) of the male migrants also did not use a condom in their last sexual intercourse. These results show that sexually active individuals do not routinely practice safe sex, leading to a high risk of HIV infection. The low rate of condom use may explain their poor knowledge about the protective effects of condoms against HIV [37]. The findings indicate that the government needs to pay more attention to interventions targeting unmarried male migrants that could be effective in improving their awareness of condom use. For example, community interventions, including lec-tubes (experts lecture), posters, brochures, and videos, could be used to help them think of condoms as a cost-effective approach to sexually transmitted diseases/HIV prevention and contraception.

Despite a majority of participants having heard of AIDS and knowing the major routes of HIV transmission, many had substantial misconceptions regarding other routes. This report is similar to reports by authorities citing knowledge of mode of transmission of HIV/AIDS among Nepalese migrants in India [9]. Here, about half of respondents did not perceive themselves to be at risk of HIV infection: also, respondents largely considered premarital sex to be acceptable. In our study, this phenomenon of risk behavior and perception of HIV/AIDS, which indicates a risk of HIV infection, highlights the need for the promotion of safer sex among migrants.

These study findings have important implications for developing HIV intervention programs targeting migrants in Shanghai. First, we found that, consistent with an earlier study [22], males that have first sexual intercourse at a younger age were more likely to report having non-regular sex partners in the previous six months, suggesting the importance of focusing on HIV prevention interventions on younger, sexually experienced males. Second, a noteworthy finding in this study was the strong association of sexual risk behavior with exposure to pornography. Those who were exposed to pornography were more likely to engage in risk behavior than those who were not. This suggests that more intense efforts should be made to improve awareness about the seriousness of exposure to pornography among unmarried males and help them to develop a proper attitude to it. Third, another noteworthy finding was that having peers who had engaged in sex with a non-regular sex partner increased the likelihood of the involvement of unmarried males in risky sexual encounters. Studies conducted in the U.S. have demonstrated that social network members can influence the behaviors of others through a variety of mechanisms, including social comparisons, social control processes, and fear of social sanctions [38, 39]. In common with other types of human behavior, our results demonstrate that peers may exert a significant influence on the sexual risk behavior of individuals. The results are also in line with those of another study, which found that the social influence of peers contributes to increased sexual risk behavior among migrants [40]. The findings imply that HIV intervention programs not only focus on individual risk takers but also on their broader social network of peers. Fourth, our analysis revealed that the number of cities to which men migrated was positively associated with higher risk sex and that participants who had a history of moving to more cities of migration were more likely to report higher risk sex. Unique HIV prevention and intervention strategies should be conducted in this population. Fifth, as expected, participants who perceived themselves to be at low risk of HIV infection were more likely to report non-regular sexual partners than those having a higher risk perception. Despite many achievements in HIV knowledge dissemination, there remains an essential need to educate migrants more extensively about HIV/AIDS prevention and transmission, and to increase personal skills in protection against HIV infection. Sixth, we found the strong protective association with sexual risk behavior of knowing someone who had or had died of HIV/AIDS and related diseases. This finding was similar to the results of a study conducted among the young in the United States [41]. Interventions need to address ways to help migrants better understand the serious consequences of sexual risk behavior, including various infectious diseases and especially HIV/AIDS. Seventh, our study also showed that many migrants had substantial misconceptions regarding HIV transmission. Therefore, interventions to improve HIV/AIDS-related knowledge need to focus on unmarried male migrants, particularly those engaging in risky behaviors and emphasize the ways HIV is not transmitted in addition to the major routes of HIV transmission. Finally, more intervention programs should target migrants, especially young unmarried males, and condom use should be emphasized strongly, targeting also non-regular sex partners.

To our knowledge, this study is the first in China to focus on unmarried male migrants, an understudied subgroup with a potentially greater risk of contracting HIV in China. Our study not only described HIV/AIDS-related knowledge, attitudes, and sexual risk behavior in this subgroup but also identified possible sexual risk behavior factors, such as earlier age at first sexual intercourse, more cities of migration, poor perception of acquiring HIV/AIDS, frequent exposure to pornography, not knowing someone who had or had died of HIV/AIDS and related diseases, and having peers who had engaged in sex with a non-regular sex partner. The results provide critical information for policy makers and sex educators to reinforce sexual health services and sex health education targeting the behavior and sexual health of unmarried male migrants.