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The rising number of migrants worldwide, including in China given its recent rapid economic development, poses a challenge for the public health system to prevent infectious diseases, including sexually transmitted infections (STIs) caused by risky sexual behaviors.
The aim of this study was to explore the risky sexual behaviors of international immigrants living in China to provide evidence for establishment of a localized public health service system.
Risky sexual behaviors were divided into multiple sexual partners and unprotected sexual behaviors. Basic characteristics, sexual knowledge, and behaviors of international immigrants were summarized with descriptive statistics. Multivariate logistic regression analyses were used to identify factors associated with risky sexual behaviors, and the associations of demographic characteristics and risk behaviors with HIV testing and intention to test for HIV.
In total, 1433 international immigrants were included in the study, 61.76% (n=885) of whom had never heard of STIs, and the mean HIV knowledge score was 5.42 (SD 2.138). Overall, 8.23% (118/1433) of the participants had been diagnosed with an STI. Among the 1433 international immigrants, 292 indicated that they never use a condom for homosexual sex, followed by sex with a stable partner (n=252), commercial sex (n=236), group sex (n=175), and casual sex (n=137). In addition, 119 of the international immigrants had more than three sex partners. Individuals aged 31-40 years were more likely to have multiple sexual partners (adjusted odds ratio [AOR] 2.364, 95% CI 1.149-4.862). Married participants were more likely to have unprotected sexual behaviors (AOR 3.096, 95% CI –1.705 to 5.620), whereas Asians were less likely to have multiple sexual partners (AOR 0.446, 95% CI 0.328-0.607) and unprotected sexual behaviors (AOR 0.328, 95% CI 0.219-0.492). Women were more likely to have taken an HIV test than men (AOR 1.413, 95% CI 1.085-1.841). Those who were married (AOR 0.577, 95% CI 0.372-0.894), with an annual disposable income >150,000 yuan (~US $22,000; AOR 0.661, 95% CI 0.439-0.995), considered it impossible to become infected with HIV (AOR 0.564, 95% CI 0.327-0.972), and of Asian ethnicity (AOR 0.330, 95% CI 0.261-0.417) were less likely to have an HIV test. People who had multiple sexual partners were more likely to have taken an HIV test (AOR 2.041, 95% CI 1.442-2.890) and had greater intention to test for HIV (AOR 1.651, 95% CI 1.208-2.258).
International immigrants in China exhibit risky sexual behaviors, especially those aged over 30 years. In addition, the level of HIV-related knowledge is generally low. Therefore, health interventions such as targeted, tailored programming including education and testing are urgently needed to prevent new HIV infections and transmission among international immigrants and the local population.
Under globalization, the number of international travelers has increased significantly worldwide during the past decade, from 2433 million in 2008 to 3188 million in 2019 [
The total number of people living with HIV/AIDS worldwide increased from 31.1 million in 2010 to 37.7 million in 2020 [
In China, the number of newly reported HIV-infected international immigrants reached up to 15,319 between 2004 and 2017 [
We used a cross-sectional web-based study design to collect data from international immigrants living in China by a snowball sampling method. Three to six international immigrants with different occupations, ages, home countries, and genders from Yiwu, Guangzhou, Beijing, and Hangzhou were invited to start the investigation. These immigrants were then asked to invite other international immigrants living in China to participate in the survey to expand the sample. We selected these locations in particular because Yiwu, as one of the largest commodity trading cities, attracts nearly half a million international immigrants every year [
The inclusion criteria of participants were: (1) international immigrants whose homeland was not China but were living in China, (2) above 18 years old, (3) could read English, and (4) willing to participate in the study. The exclusion criteria were: (1) under 18 years old; (2) Chinese nationality; and 3) did not pass the “attention check” in the questionnaire, which was used to identify careless respondents and improve the data quality.
The sample size was calculated based on the 31.14% HIV diagnosis risk among international immigrants according to previous studies [
Considering the sensitivity of sexual issues and the COVID-19 pandemic, we used an online questionnaire rather than a face-to-face survey, which was conducted between January and September 2021, including sociodemographic information (eg, gender, age, marital status, education level, employment, and annual disposable income), HIV-related knowledge, STIs history (eg, diagnosis of genital herpes, syphilis, and condyloma in the past), HIV testing history (ie, have taken an HIV test in the past), and intention to have an HIV test in the future.
In addition, all participants were invited to recall their related sexual behaviors while living in China in the past year. Sexual behavior–related data included the number of sexual partners; condom use; stable, casual, commercial, homosexual, and group sexual behaviors; as well as illicit drug use. Risky sexual behaviors were classified as having multiple sexual partners and unprotected sexual behaviors. HIV-related knowledge was measured using the 8-item HIV Knowledge Questionnaire (HIV-KQ-8) [
The study protocol and consent procedure were approved by the Ethics Review Committee, School of Public Health, Zhejiang University (#2019-064). Informed consent information was provided before the questions; participants had the option to exit the survey after reading the informed consent information or to provide consent to continue. The confidentiality of individuals was properly protected in the management of the investigation and the processing of data.
Descriptive statistics were used to analyze the basic characteristics, sexual-related knowledge, and sexual behaviors of international immigrants using frequency and percentage or mean (SD) as appropriate. Univariate and multivariate logistic regression analyses were used to identify the factors associated with risky sexual behaviors among international immigrants and the association with HIV test history and intention to receive an HIV test in the future. SPSS 24.0 statistical software (IBM, Armonk, NY, USA) was used to analyze all data.
In total, 1433 international immigrants were included in the study, with a predominance of men (
Basic characteristics of international immigrants in China (N=1433).
Characteristics | Value | |
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||
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Male | 973 (67.90) |
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Female | 460 (32.10) |
Age (years), mean (SD) | 24.97 (4.57) | |
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Unmarried | 1263 (88.14) |
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Married | 110 (7.68) |
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Windowed | 4 (0.28) |
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Divorced | 9 (0.63) |
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Other | 47 (3.28) |
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Illiterate | 49 (3.42) |
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1-5 years | 299 (20.87) |
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6-10 years | 97 (6.77) |
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11-12 years | 157 (10.96) |
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>12 years | 831 (58.00) |
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Employed | 231 (16.12) |
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Unemployed | 1202 (83.88) |
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≤50,000 | 1040 (72.58) |
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50,001-100,000 | 212 (14.79) |
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100,001-150,000 | 79 (5.51) |
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>150,000 | 102 (7.12) |
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Africa | 679 (47.38) |
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America | 67 (4.68) |
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Europe | 40 (2.79) |
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Asia | 610 (42.57) |
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Other | 6 (0.42) |
aExchange rate on December 7, 2021: 6.3708 yuan=US $1.
bThere were 31 responses missing.
Among the 1433 international immigrants, 61.76% (885) had never heard of STIs or HIV. Among the immigrants who had heard of HIV/STIs, the mean knowledge score on HIV was 5.42 (SD 2.138). The percentage of respondents with an HIV knowledge score <4, 4-6, and >6 was 6.98% (100/1433), 17.31% (248/1433), and 13.89% (199/1433), respectively.
Overall, 91.77% (1315/1433) of international immigrants had not been diagnosed with any STIs, whereas 8.23% (118/1433) of the international immigrants had been diagnosed with at least one STI, including gonorrhea (16/1433, 1.12%), syphilis (12/1433, 0.84%), condyloma acuminatum (1/1433, 0.07%), herpes progenitalis (3/1433, 0.21%), hepatitis B (9/1433, 0.63%), and hepatitis C (2/1433, 0.14%). In addition, 4.82% (69/1433) of the participants had been diagnosed with HIV.
As shown in
Frequency of condom use according to sexual behavior among international immigrants.
The binary logistic regression model showed the factors affecting whether the respondents had multiple partners or unprotected sex as a risky sexual behavior (see Table S1 in
Table S2 in
International immigrants in China exhibited risky sexual behaviors, with 22.40% and 13.19% of the respondents reporting having multiple sexual partners and unprotected sexual behaviors, respectively. These trends may be partly related to the differences in the new living environment faced by international immigrants from those of the homeland. For example, the absence of family and peer monitoring, language barriers, cultural barriers, and a sense of anonymity may offer immigrants more sexual freedom [
HIV knowledge is a significant factor contributing to HIV prevention [
The age group of 30-60 years was significantly associated with having more risky sexual behaviors among the international immigrants surveyed in our study, which was consistent with the majority of previous related studies. This may be related to the fact that this age corresponds to a more physiologically sexually active group, who may have sex with multiple partners without protection. A previous study published in 2018 also reached a similar conclusion, showing that adults of this age group were more likely to have sex without a condom, new sexual partners, and multiple sexual partners [
With respect to the influence of the origin region of the immigrants, we found that Asians exhibited less risky sexual behaviors but also had reduced intention to be tested for HIV compared with Africans. The possible reasons for these differences may include that polygamy still exists in some areas of Africa, especially in some sub-Saharan African countries [
This study had some limitations. First, it is possible that the participants were influenced by social and cultural norms to hide their risky sexual behavior, including a history of commercial or casual sexual behaviors, which may affect the research results, although an online survey could avoid the embarrassment caused by a face-to-face survey. Second, although the seed participants were selected to have different occupations, ages, homelands, and genders from different cities, a bias caused by snowball sampling may still exist, which could lead to misinterpretation of the related statistical results. In addition, considering the significant number of international immigrants living in China, our participants were mainly from lower socioeconomic strata with a lower annual disposable income, which represents a narrow band of the socioeconomic system. Therefore, the results may not be generalizable to the whole population. Third, the questionnaire regarding risky sexual behaviors was designed based on previous work and was amended according to our research participants and objectives. Thus, the validity of the questionnaire in the survey should be further tested.
Globalization leads to an inevitable trend of increased population mobility. Under this situation, it is necessary to take proactive public health approaches to manage the health of international immigrants, especially with respect to infectious diseases. Our study showed that the overall HIV-related knowledge of the international immigrants in China was low along with a low rate of intention to test for HIV. Therefore, HIV-related education is essential, such as by community advocacy and online propaganda delivered in their native languages, to address the gaps in HIV knowledge among international immigrants. More importantly, it is difficult for international immigrants to access HIV-related services because of the lack of specified health care and prevention upon arrival in the new country, which may cause immigrants with an HIV-positive status to remain undiscovered until some typical symptoms appear. To prevent the transmission of HIV, the basic public health care services provided by the Chinese government should be extended to cover international immigrants. Active promotion for antiviral treatment is less available for international immigrants with HIV infection than for local residents in China. Thus, an integrated health system for HIV prevention, monitoring, and treatment for immigrants and local residents will be important to reduce the transmission rate of HIV. Moreover, this is also necessary to reduce the inequities in access to health care and health outcomes for immigrants. It is also important to consider the wider health care and socioeconomic barriers immigrants face to be successful in improving HIV outcomes. In addition, as a convenient and efficient method, HIV self-testing could be promoted among international immigrants, such as setting up rapid detection kit vending machine in immigrant gathering communities [
Risky sexual behaviors exist among international immigrants in China, including multiple partners and unprotected sexual behaviors, and the level of cognition of HIV knowledge was quite low, especially for married immigrants and those aged above 30 years. Therefore, there is an urgent need to promote health education and HIV testing specified for international immigrants. In addition, it is also important to develop and improve health care access for international immigrants under the current situation of increasing globalization.
Factors associated with risky sexual behaviors (Table S1), and demographic characteristics, risk behaviors, and their association with HIV testing and intention to test for HIV (Table S2) among international immigrants.
adjusted odds ratio
8-item HIV Knowledge Questionnaire
sexually transmitted infection
We are grateful to all study participants for their valuable participation. This work was supported in part by the National Natural Science Foundation of China (Project No. 71904171); China Medical Board (Project No. 20-391 and 202033); Zhejiang Provincial Soft Science Research Project (Project No. 2021C35015); Research Fund, the Vanke School of Public Health, Tsinghua University (Project No. 2021ZZ004); Sanming Project of Medicine in Shenzhen (Project No. SZSM202111001); and National Key R&D Program of China during the 14th Five-Year Plan Period (Project No. 2021ZD0114102).
The views expressed in this publication do not represent the views of the Veterans Health Administration or the United States Government.
All authors were responsible for the structure of this paper. YZ conducted the literature review, data analysis, and drafted the paper. JX contributed to the study’s conception and design, interpretation of the data, and critical revisions of the paper. FC provided interpretation and revisions of the manuscript. All authors approved the final version of the manuscript.
None declared.