Mo0PB02 06 Xiaoyan Su

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Population-based behavioral surveillance of male clients of female sex workers in Hong Kong from 1998 to 2006 Joseph Lau, Professor Xiaoyou Su, PhD candidate Centre for Epidemiology & Biostatistics School of Public Health, Faculty of Medicine The Chinese University of Hong Kong The 8th International Congress on AIDS in Asia and the Pacific (8th ICAAP), August 19-23, 2007 August 21, 2007

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Principal Investigator: Prof. Joseph T.F. Lau Other research team members: Ms. M.W. Chan Ms. H.Y. Tsui Ms. Xiaoyou Su Research Team Members

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By the end of the 1st quarter of 2007, 3289 HIV/AIDS cases reported in Hong Kong - 80.5% in men - 49.6% via heterosexual transmission 1. Advisory Council on AIDS (2007 Background

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 Behavioral surveillance surveys (BSS)2 Systematic, repeated, cross-sectional surveys of HIV/STD-related behaviors  Uses of BSS3 -serves as an early warning system -tracks changes of behaviors/incidence -evaluates program effectiveness & informs program design 2. Mills S et al. (1998); 3. Amon J et al. (2000) Background

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Study Design  Population-based surveys  Anonymous cross-sectional random telephone surveys Study Population  Hong Kong men aged between 18 and 60 Methodology  Identical methodology was used in all 6 surveys 1998 (n=1,020), 1999 (n=2,074), 2001 (n=2,065), 2004 (n=2,004), 2005 (n=2,008), and 2006 (n=2,027)  A structured questionnaire was used to collect data Methods

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Conventional Method (TI) Computer -assisted Method (TICQ) Administered by the interviewers Administered by the interviewers Respondents key in their responses to the pre-recoded questions Part I: Less sensitive questions Part II: More sensitive questions Questionnaire Computer-Assisted Telephone Survey Method

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e.g., Among Males % Had sex with FSW in the last 6 months 3.9% 11.1% p<0.01 % Had sex with a non- regular sex partners 5.1% 14.6% p<0.01 in the last 6 months Among Females % Had one-night-stand in the last 6 months 0% 4.0% p<0.01 5. Lau et al. (2003a). Methods TI TICQ

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Background characteristics of all respondents 1998 1999 2001 2004 2005 2006 p (2 trend) % % % % % % Age group 18 – 40 76.9 71.6 67.7 53.7 53.5 53.8 <.001 Education level Matriculated 34.4 36.3 39.0 41.7 46.0 44.8 <.001 Marital status Single NA NA NA 37.1 34.7 37.8 0.64 Level of HIV-related knowledge # 16.2 18.5 21.7 26.1 32.7 30.4 <.001 # Mentioned 3 correct routes of HIV transmission. Statistical adjustment required and was implemented in analyses. Summary of Main Findings

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% Had sexual intercourse with female sex workers (FSW) in the last 6 months (among all respondents) p=0.124 Over the years, around 11% or so engaged in commercial sex. Adj.OR 1.00 0.86 0.79* 0.93 0.93 0.90 *p<0.05 Summary of Main Findings

Photos – In Hong Kong: 

Photos – In Hong Kong

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Surveillance of behaviors in male clients of FSW Background characteristics of those who had sex with FSW in the last 6 months 1998 1999 2001 2004 2005 2006 p (2 trend) % % % % % % Age group 18 – 40 80.4 75.9 67.7 59.1 61.6 53.2 <.001 Education level Matriculated 19.7 22.7 30.0 30.4 35.1 35.5 <.05 Marital status Single NA NA NA 40.1 36.2 37.2 0.52 Level of HIV-related knowledge # 14.7 20.2 21.1 22.4 34.1 33.8 <.001 # Mentioned 3 correct routes of HIV transmission. Summary of Main Findings

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% Had sex with FSW in mainland China (among those who had had sex with FSW in the last 6 months) Adj.OR 1.00 1.77** 1.18 0.67 0.80 0.72 Adj. OR: Odds ratios adjusted for age, education level and HIV-related knowledge. *p<0.05 About 40% engage in cross-border commercial sex, though a slight decline was noted. Summary of Main Findings

Photos – In ShaTsui (Shenzhen,China): 

Photos – In ShaTsui (Shenzhen,China) Source: The Sun Daily, and Ming Pao

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% Used condoms every time when having sex with FSW (among those who had had sex with FSW in the last 6 months) Adj.OR 1.00 1.12 1.26 1.25 1.01 0.84 Adj. OR: Odds ratios adjusted for age, education level and HIV-related knowledge. *p<0.05 Remaining 1/3 did not use condoms consistently with FSW, quite stable. However… Summary of Main Findings

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% Consistent condom use with FSW (among those having sex with FSW in mainland China ) versus % Consistent condom use with FSW (among those having sex with FSW in Hong Kong ) Declining Increasing Summary of Main Findings

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% Consistent condom 1998 1999 2001 2004 2005 2006 use with FSW in the last 6 months (Adjusted OR) Among those had sex 1.00 1.64 1.68 1.64 2.06* 2.26* with FSW in China Among those had sex 1.00 0.88 0.96 0.74 0.40* 0.31** with FSW in Hong Kong Adj. OR: Odds ratios adjusted for age, education level and HIV-related knowledge. *p<0.05 Summary of Main Findings

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Apparently no change in condom use with FSW  1/3 did not use condoms consistently with FSW  Improvement was offset by deterioration  Cross-border commercial sex acts were prevalent Discussion

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 During 1998 to 2001, Hong Kong male clients of FSW tended to be more likely to use condoms in Hong Kong as compared to in mainland China (OR=2.56, p<0.001) 6 6. Lau & Tsui (2003). Discussion HK M China

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Reasons for differences from1998 to 2001  Drug-use in China  Weaker perceived control among FSW in China  Support from keepers of establishments in Hong Kong Lau et al. (2003b). Discussion

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 Improvement in China  Many years of prevention education  Perceived risk reversed e.g., Perceived high chance of HIV infection via sex with FSW 7 1994 2005 In China: 80% 90% In Hong Kong: 63% 45%  Removal of lower-end establishments in Shenzhen  Education of FSW by Shenzhen CDC and other institutes 7. Lau et al. (2007). Discussion

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 Deterioration in Hong Kong ???  Reasons not known  Efforts overlooked  Changes to free-lance sex workers   Future research Discussions

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 Condom use is context-specific, both improvement and deterioration could occur  Hong Kong still at risk, as 30% are not consistent condom users Conclusions

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All study participants The Hong Kong Council of the AIDS Trust Fund Acknowledgements

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---End of Presentation--- Thank you for your attention!